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Investigation and inquest
On 22nd of May 2024 I opened an inquest into the death of Andrew Michael Lewis. The inquest was conducted on 6th of December 2024.
The cause of death was:
1a) Acute on Chronic Gastrointestinal Haemorrhage
1b) Bleeding Oesophageal Varices
1c) Alcoholic Liver Cirrhosis
2) Low volume Subdural Haemorrhage
The conclusion of the inquest was:
Alcohol-related, contributed to by head injury.
Circumstances of the death
Andrew Lewis was a 55 year old man who died at home on the 7th of May 2024.
He called 111 at 13:42 on 7th of May 2024, reporting weakness in his legs and an earlier fall.
The key times are:
13:42 Called 111, categorised as Cat 3 (ie response time within 120 minutes for 90% of calls). This decision required confirmation by a clinician within South Central Ambulance Service (‘SCAS’), as the original call was to 111.
15:17 SCAS categorised the call as Category 3. The 120 minute ‘clock’ began to run at this point. An ambulance should therefore have been in attendance by 17:17.
23:45 Ambulance arrived. Andrew was deceased. This ambulance arrived because family and police had attended the property, broken in and found him unresponsive – the call was then categorised as Category 1 (the most urgent category).
I accepted at inquest that the reason for this chronology was that there was simply no ambulance to send earlier.
Coroner’s concerns
Facts of this case
An ambulance resource arrived around 10 hours from Andrew’s first call (to 111 services), and 8 ½ hours after the ambulance service categorised this as a call requiring attendance within 2 hours.
South Central Ambulance Service generally
The NHS has a framework called OPEL (Operational Pressures Escalation Level), designed to manage capacity at times of excess demand. SCAS’ version of this is called REAP (Resource Escalation Action Plan).
The levels are:
REAP level 1 – Steady state.
REAP level 2 – Moderate pressure.
REAP level 3 – Major pressure.
REAP level 4 – Extreme pressure.
There are also categories for critical incidents and major incidents.
I obtained information from South Central Ambulance Service about their escalation levels in the last 2 years. The specific data can be provided, but the headlines (for the period 3rd of August 2022 to 9th of October 2024) are:
• SCAS has been at REAP 3 or above for 90% of this time period. They have been constantly at REAP 4 since 9 October 2024.
• The lowest escalation level that this ambulance service has been at in this period is REAP 2. They have never been at steady state (REAP 1) during this period.
• I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.
The national picture
1. In the period July 2013 to 24th November 2024, 217 Prevention of Future Deaths Reports (‘PFDs’) were written to ambulance trusts. It is fair to say that not all of these will relate to delay, but a significant number of them do.
2. There appears to be no oversight of this issue, and a number of ambulance trusts have not responded to these reports at all.
3. I have attached an article published by the Preventable Deaths Tracker in November 2024, which provides further information regarding ambulance PFD reports.
Information checked against the published report and official responses