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Investigation and inquest
On 13 February 2023, I commenced an investigation into the death of Lynda BLACKMORE. The investigation concluded at the end of the inquest on 1st November 2023. The conclusion of the inquest was: -
The deceased died due to overwhelming infection, on a background of chronic and deteriorating significant natural disease.
I determined the medical cause of her death to be:-
1a Sepsis
1b Leg cellulitis due to chronic leg oedema
1c Congestive cardiac failure
II Type 2 diabetes mellitus, ischaemic heart disease
Circumstances of the death
I recorded the following in respect of How, When and Where she came about her death:-
Lynda Blackmore had established heart failure and diabetes mellitus. In early 2023 there was a further deterioration in her symptoms leading to a painful, bruised and swollen left leg. On 1st February 2023 she became acutely unwell and her GP attended upon her at her home. This led to an emergency call to the ambulance service for urgent conveyance to University Hospital Wales, Heath for specialist vascular treatment. There was a delay in the arrival of the ambulance of some thirteen hours likely due to a combination of mis-categorization of the response, resource availability and hospital handover delays. By the time of her arrival she was diagnosed with sepsis. Whilst treatment was initiated, she did not respond and died there later the same day. The delay in the instigation of necessary treatment likely contributed to her death.
Coroner’s concerns
The investigation focused upon the causal significance, if any, of a delay of some thirteen hours, or thereabouts in the provision of an ambulance to the deceased.
I received written & oral evidence from Andrew Garner of the Welsh Ambulance Service Trust ( I annex a copy of his witness statement). I refer you in particular, to paragraph’s 43-49.
My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital. As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
Information checked against the published report and official responses