Grenville Wait · Prevention of Future Deaths report

On 3rd February 2022, I opened an inquest into the death of Grenville Wait who died on 6th November 2021 at home, aged 83 years. The investigation concluded with an inquest which I heard on 22nd June 2022, and which concluded that Mr Wait had died as the consequence of an accident.

Mr Wait fell whilst out shopping on 2nd November 2021. He was taken to hospital where a fractured sternum was diagnosed. Mr Wait was discharged home with advice about taking regular analgesia and a plan to follow-up with a fracture clinic appointment.

On 6th November 2021, a family member found Mr Wait deeply unconscious in bed with altered breathing. A 999 call was made, and an emergency ambulance dispatched by way of a category 2 response, the call having been incorrectly coded as a category 2 rather than a category 1 call.

The ambulance arrived around 70 minutes after the time of the original 999 call, outside of the target range for category 2 calls.

Around the time of the ambulance crew’s arrival, Mr Wait went into cardiac arrest and could not be resuscitated. A post mortem examination determined Mr Wait died as a consequence of:-

1a) Pneumonia on background of fractured sternum

2) Ischaemic heart disease.

1) Notwithstanding the steps North West Ambulance Service NHS Foundation Trust has taken via its patient safety plan to manage and respond to demands on its service, it is a matter of concern that target response times are still routinely not being met nationally. By way of illustration, the court heard evidence that on 21st June 2021, the Trust’s average response time for a category 2 call was 50 minutes with the response time to 90% of all relevant incidents of 1 hour and 48 minutes.