Ronald Hamer · Prevention of Future Deaths report

On the 16th February 2016 I opened an inquest into the death of Ronald Hamer. I concluded that the inquest on the 13th April 2016. The conclusion of the inquest was Accidental Death.

The deceased was an independent elderly gentlemen living at his home at ████████, ████████. On the morning of the 8th February 2016 he slipped and fell in the bathroom of his home sustaining an injury to his right arm. He became immobilised on the floor remaining in an awkward position whereby his right arm was trapped by his body. This incident occurred around 5am and he was not discovered by his family until around 6:45pm - over 13½ hours later. A call to the emergency services was made at around 6:50pm with the ambulance arriving shortly before 9:30pm. Mr Hamer was conveyed to Prince Charles Hospital in Merthyr Tydfil but despite treatment his condition deteriorated and he died there on the morning of the 10th February 2016.

1) As against an internal Welsh Ambulance Services Trust response target time for an Amber 2 call of 20 minutes, an ambulance did not arrive at the scene for nearly 2 hours and 40 minutes. It was accepted in evidence on behalf of the Welsh Ambulance Services Trust that this response time was unacceptable and that the situation could happen again.

2) Cognisant of the delay in responding to the original call to the emergency services, good practice of the Welsh Ambulance Services Trust would have been to have made a phone call(s) to seek an update on the condition of the patient, to provide further advice and to ascertain whether it would have been appropriate to re-categorise the call. A call was not made to the family of the deceased (and this was disputed in evidence in any event) until just before 8:25pm, 1½ hours after the original call had been made.

3) The evidence suggested that at or around the time of the first call being made to the Welsh Ambulance Services Trust at around 6:50pm on the 8th February 2016 there was an extremely high number of calls being polled. The evidence suggested that there was an absence of clear planning and direction as to the maintenance and delivery of the Trust's services and that in repeat circumstances of such significant polling the same circumstances as found at the inquest of Mr Hamer could repeat themselves.