Keith Hopwood · Prevention of Future Deaths report

On 30th September 2021 I commenced an investigation into the death of Keith Hopwood. The investigation concluded on the 17th May 2022 and the conclusion was one of: Narrative: Died from a myocardial infarction whilst awaiting the arrival of an ambulance. The medical cause of death was 1a) Myocardial Infarction; 1b) Stenotic Coronary Artery Atheroma; and II) Hypertension, Diabetes Mellitus

On 29th September 2021 at 11:28 Keith Hopwood called an ambulance as he had fainted and felt very unwell. His call was assessed at a category 3. An ambulance was dispatched to his home address at 11:38. It was rerouted to a more urgent call at 11:43. At 12:50 Keith Hopwood was spoken to by a clinician. He reported chest pains and feeling very unwell. The call was suddenly disconnected. Mr Hopwood should have been upgraded to a category 2 but was not. A private ambulance under contract to NWAS was dispatched at 13:17 and arrived at 13:34 at his home address ████████. Keith Hopwood was unresponsive and could not be resuscitated. Post mortem examination found he had died from a myocardial infarction due to stenotic coronary artery atheroma.

1. The inquest heard that the delays in relation to the ambulance service were due to significant resource issues for all ambulance services not just North West Ambulance Service. The inquest was told that the shortages were due to staffing levels and demand. Steps had been taken to try to increase resources but the ambulance service was still struggling to meet the demand. In this case it was clear that had the initial ambulance not have been rerouted due to demand and pressure on services that he would have been alive when he was seen and have been transported to hospital;
2. The inquest heard that in the initial call to the ambulance service he was told to call back if he got worse in any way. His response was to say that he couldn’t feel any worse than he had in the last 10 minutes. The algorithm driving the conversation did not direct that this response should require exploration of symptoms and why he had made this comment. As a consequence an opportunity to explore his presentation further was lost;
3. The ambulance that arrived was a private ambulance and not equipped to deal with a cardiac patient. If the second call had been correctly categorised it would not have been dispatched as private ambulances are deployed with less qualified staff to calls categorised as 3 and 4 due to a lack of NHS Ambulance resources. As a consequence a further ambulance had to be deployed to the scene when Mr Hopwood was found to be unresponsive;
4. The second call from Mr Hopwood disconnected. Because he was alone a disconnection does not automatically result in an escalation of a call. Had he been with someone who said he had become unresponsive that would have generated a different approach.