Rita Maureen TAYLOR · Prevention of Future Deaths report

On 07 October 2022 I commenced an investigation into the death of Rita Maureen TAYLOR aged 84. The investigation concluded at the end of the inquest on 17 January 2023. The conclusion of the inquest was that:

The deceased suffered an unwitnessed fall at her home, 43 Dodkin, Beanhill, Milton Keynes and suffered a head injury. An ambulance was called at 10.28 but due to lack of resources did not arrive until 17.17. When she arrived at Milton Keynes University Hospital at 17.58 her Glasgow Coma Score was 3. A CT scan revealed a large intracerebral bleed. She died the same day at the hospital. The delays in sending an ambulance resulted in a number of lost opportunities to admit her to hospital and begin her treatment.

As outlined above and in Coroner’s concerns

I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes.
The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. [At] that time there were "no available resources to send."
At 11.12 a 999 call was made by a passer by but there were still "no available resources ".
At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ".
At 12.41 a call was made to Mrs. Taylor’s location but there were " still no available resources to send".
At 13.12 A further 999 call was made " awaiting resources to become available"
At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources".

At 14.42 further 999 call but again "no available resources".
At 15.25 Case reviewed to a category 2.
At 16.29 An ambulance was dispatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade.
Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Coma score was recorded as 3.She died later the same day.