Reginald Dixon · Prevention of Future Deaths report

On the 10 July 2017, I commenced an investigation into the death of the late Mr Reginald Dixon. The investigation concluded at the end of the inquest on 4 September 2017. The conclusion of the inquest was a short form conclusion of accidental death.

The cause of death was:

1a Aspiration Of Gastric Contents
b Subdural And Traumatic Subarachnoid Haemorrhage
c Skull Fractures And Cerebral Contusions
II Systemic Hypertension, Left Clavicle, Left Rib And Left Neck Of Femur Fractures

i) On the 26th June 2017 at 1853 hours a 999 call was received by West Midlands Ambulance Service (WMAS) to reports of a 70-year-old male, Mr Dixon who had an unwitnessed fall downstairs sustaining a head and back injury.

ii) Initially it was reported the patient was conscious and breathing. The location of the incident was in Norton, Stourbridge. The call was triaged through Pathways and a category 3 response assigned. At that time, there was no available resource to immediately assign to the case.

iii) At 1921 hours a second 999 call was received for the patient and this to was triaged through Pathways and a category 3 response assigned. It was reported that the patient’s condition had changed and they were now vomiting and becoming drowsy. There was still no available resource to immediately assign to the case.

iv) At 1931 hours a third 999 call was received for the patient and it was reported that the patient’s condition had deteriorated further and following triage a category 2 response assigned. An ambulance was assigned to the case within 4 minutes but was some distance away from the incident.

v) At 1945 hours a fourth 999 call was received and during this call the ambulance arrived on scene at 1950 hours, 57 minutes from the time of the original call.

vi) The patient was found by the ambulance crew with a lowered conscious level and multiple injuries. Following assessment, the patient was conveyed to the major trauma centre during the transfer the crew were intercepted by the MERIT team, who anaesthetised the patient prior to continuing to hospital.

vii) He was taken to Queen Elizabeth Hospital, Birmingham where it was identified the patient had an un-survivable head injury and wasn’t deemed suitable for neurosurgery and sadly passed away the same day.

1. Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level 3. The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time.

2. Evidence also emerged during the inquest that there were insufficient resources available and average response times of 29 minutes. This delay posed a risk to patients.