Barry Stuart Hodges · Prevention of Future Deaths report

On 01/09/2016 I commenced an investigation into the death of Barry Stuart Hodges, 69 . The investigation concluded at the end of the inquest on 20 April 2017. The conclusion of the inquest was a narrative conclusion. On the 23rd August 2016, Mr Hodges collapsed at Doncaster Tennis Club. An ambulance was called and coded Amber with a 19 minute response time but did not attend until 41 minutes after the initial call was made.

On arrival, the paramedics found Mr Hodges to be in cardiac arrest, he was assessed and transferred to Doncaster Royal Infirmary where he was pronounced deceased.

It is not possible to ascertain if the outcome would have been different if the ambulance had arrived sooner, although with a cardiac arrest any delay in treatment leads to a poorer prognosis.

Mr Hodges appeared to be a fit 69 year old man who regularly played tennis. On the 23rd August 2016 Mr Hodges complained of chest pains and collapsed at the Tennis Club.

An ambulance was called at 19:12 hours and there were two resources available at this time. These were not allocated due to the incident being uncoded. At 19:14 hours, Mr Hodges was coded amber with a response time of 19 minutes, but the despatcher did not review the resources available at the time of coding or within 2 minutes as set down in the protocol. No resources were allocated but potentially two were available.

The protocol also states that a review of resources should take place every 10 minutes following coding but this did not occur.

The first review of resources occurred at 19:28 hours when a resource was available but not allocated, and again at 19:35 hours when a resource was available but again not allocated.

Mr Hodges' condition deteriorated and a second call was made to Yorkshire Ambulance Service at 19:46 hours. At 19:47 hours, Mr Hodges was recoded as red and resources were allocated arriving at the scene at 19:53 hours.

Bystander CPR was taking place when paramedics arrived at 19:53 hours. Mr Hodges was transferred to Doncaster Royal Infirmary but he was declared deceased a short time after arrival.

The cause of death is:-

1a) Left ventricular failure;
1b) Ischaemic heart disease;
1c) Coronary artery atheroma.

(1) Protocols for ambulance dispatch and review of resources were not adhered to and there appeared to be an absence of any system to “safety net” should an individual operative not manually refresh and look at the system.

(2) A lack of knowledge/training/understanding of the protocols that 4 resources were available at different times but none were utilised.

(3) Time scales were breached without further action ie. escalation to Senior Management, Clinicians or allocation of resources.