Nicola Emma OWENS · Prevention of Future Deaths report

On 07 October 2024 I commenced an investigation into the death of Nicola Emma OWENS aged 40. The investigation concluded at the end of the inquest on 30 January 2025. The conclusion of the inquest was that:

Cause of Death

1a. Hyperosmolar Hyperglycaemic State
b. Undiagnosed Type 2 Diabetes Mellitus

II. Morbid Obesity

Narrative Conclusion

The unavailability of an ambulance to convey Nicola to hospital for necessary emergency treatment for undiagnosed type 2 diabetes mellitus resulting in a terminal cardiac event. This being a preventable death.

On 07 October 2024 I commenced an investigation into the death of Nicola Emma OWENS aged 40. The investigation concluded at the end of the inquest on 30 January 2025. The conclusion of the inquest was that:

Nicola Emma Owens was a 40 year old lady who had numerous co-morbidities, including obesity and a recent history of vomiting and diarrhoea. At approximately 14:00 hours on 4 October 2024 Nicola suffered a collapse whilst at work. She felt generally unwell but was talking. Five 999 calls were made to North-West Ambulance Service requesting their attendance. Paramedics arrived at 21:50 hours, by which time Nicola had deteriorated. She was placed in the ambulance where she proceeded to suffer a cardiac arrest at 22:40 hours. Nicola was then conveyed to the Royal Liverpool University Hospital at 22:49 hours having ongoing cardiopulmonary resuscitation (CPR), despite active treatment Nicola was pronounced deceased at 00:25 hours on 5 October 2024. The post mortem examination found Nicola died as a result of hyperosmolar hyperglycaemic state (HHS) caused by undiagnosed type 2 diabetes mellitus. HHS is a life-threatening complication of diabetes and occurs when the blood glucose (sugar)

levels are too high for a long period leading to severe complications, including hyperkalaemia. HHS is a medical emergency and without treatment, it carries a high risk of mortality. Nicola did not appear to be critically unwell following her collapse but became progressively more unwell whilst waiting 7 hours and 28 minutes for an ambulance to arrive. From the evidence heard it is more likely than not, had Nicola been conveyed to hospital earlier the potassium salt levels could have been reversed and she would have survived. High potassium salt in the blood leads to cardiac arrhythmias and is treatable and reversible on most occasions. The cause for the delay in an ambulance attending to Nicola was due to the unavailability of ambulances at that time. This delay being significantly contributed to by the handover delays across numerous hospitals across the North-West. A significant factor contributing to the handover delays in the Royal Liverpool University hospital was a backlog of patients who were fit for discharge but awaiting social care packages.

The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.