Brian JAMES · Prevention of Future Deaths report

On 5 November 2021 I commenced an investigation into the death of Brian JAMES . The investigation concluded at the end of the inquest on 11/01/2024. The conclusion of the inquest was Mr James died following a fall at his home. A delay in ambulance response and admission may have affected the treatment available to Mr James.

Medical Cause of Death:-

1a Cerebral Haemorrhage Following Fall

1b

1c

II

These were recorded as :-

Brian JAMES aged 91 years suffered a Cerebral haemorrhage following fall at home. He lived at home with his brother. He got up in the night to pass water due to his overactive bladder and fell out of bed. He hit his head ( suffered abrasion) he did not lose consciousness and was alert and talking when police and fire came to assist as his brother could not get him back into bed. Ambulance was contacted however there was a delay of around 9 hours until their arrival.

His brother came to do a courtesy visit the following morning and he was found in bed GCS 3 and covered in his own vomit. CT head showed cerebral haemorrhage. CT head findings discussed with neurosurgeons who said this man would not be for surgical intervention
He sadly passed away in hospital on 1st November 2021.

The Inquest focused upon:-

(i) The events of 30 October 2021 and leading to admission

(ii) whether any delay in admission to hospital and medical treatment was causative (more than minimally contributory) to death.

(1) A script used by Operators within WAST as part of the Clinical Safety Plan inform callers not to call back for an estimated time of arrival of the ambulance. They are told to only call back if there is a deterioration in the patient’s condition.

(2) During periods of a delayed response from an ambulance, WAST best practice is for an Operator to maintain regular contact with callers to assess any change in their condition. During periods of excessive demand, it is considered that this is not always achievable, and therefore Welfare calls are prioritised to callers considered vulnerable.

(3) There may be a risk that callers do not understand the instruction to only call back if there is a deterioration, and/or may not recognise a deterioration, and feel they cannot call WAST again. There is a further risk that unless regular welfare calls are made during periods of delayed response, there is a missed opportunity to properly re-assess and re-grade the response to a call by WAST.