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Albert James HAND · Prevention of Future Deaths report View report

9 Jan 2014 Bedfordshire and Luton T. Osborne

Albert James Hand suffered a fall at the Arndale Shopping Centre in Luton on 1 November 2013 and experienced a delay of almost one and a half hours before arriving at hospital, during which his Glasgow Coma Scale fell from 11 to 7. The concerns identified were delays in conveying patients with head injuries, insufficient ambulance crews in the Luton and Bedfordshire area, and emergency-call protocols that may put patients at risk and result in future deaths.

Michael Jonathan Davies · Prevention of Future Deaths report View report

25 Apr 2019 Carmarthenshire and Pembrokeshire J. Layton

Michael Jonathan Davies, aged 52, became unresponsive after contacting emergency services about pains down his arms and back and died at home before the ambulance arrived. The inquest recorded that he died from an acute myocardial infarction and that delayed medical treatment may have contributed to his death. The report raised concerns that chest pains and related conditions were categorised as Amber 1 rather than Red, resulting in a response time of up to four hours and potentially putting patients’ lives at risk.

Kyle William Lowes · Prevention of Future Deaths report View report

26 Aug 2016 North Northumberland T. Brown

Kyle William Lowes, aged 16, died after his motor scooter collided with a car in Berwick-upon-Tweed on 30 January 2015. Emergency response was delayed because the nearby Berwick ambulance crew was on a meal break, requiring a paramedic to travel from Wooler; the report raised concerns about delayed responses to life-threatening incidents in Berwick-upon-Tweed when only one crew is available or is outside the area.

Dorothy Anne Jones · Prevention of Future Deaths report View report

20 Jan 2023 Gwent C. Saunders

Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.

Donna Georgina Smith · Prevention of Future Deaths report View report

22 Jan 2024 Teesside and Hartlepool C. Bailey

Donna Georgina Smith suffered chest pain at home on 17 July 2021, deteriorated into cardiac arrest, and died shortly after arriving at hospital. The report identifies concerns that her worsening condition was not recognised or escalated from Category 2 to Category 1, that the methods for detecting deterioration were not sufficiently robust, and that the ambulance response took one hour and six minutes.

Brian Mills · Prevention of Future Deaths report View report

17 Nov 2016 Hertfordshire G. Sullivan

Brian Mills, an 88-year-old man on warfarin, fell at home and sustained multiple injuries, including broken ribs and a bleeding head wound. An ambulance was called, but a rapid response vehicle arrived over two hours later and an ambulance arrived subsequently; he died on 13 April 2016. The principal concern was that consistently high levels of outstanding emergency calls and excessive waiting times could put lives at risk. Evidence heard at the inquest stated that the ambulance delay did not, in this case, cause or contribute to his death.

Barry Stuart Hodges · Prevention of Future Deaths report View report

24 Apr 2017 South Yorkshire (Eastern) S. Slater

Barry Stuart Hodges, a 69-year-old man, collapsed with chest pains at a tennis club on 23 August 2016 and died after being transferred to hospital following cardiac arrest. The report identified failures to follow ambulance dispatch and resource-review protocols, insufficient safety-netting and apparent gaps in staff knowledge or training, with available resources not allocated and escalation not undertaken when timescales were breached.

Andres Roberts · Prevention of Future Deaths report View report

23 Sep 2020 Swansea and Neath Port Talbot C. Phillips

Andres Roberts suffered a large stroke and was taken to Morriston Hospital after four emergency calls, with the ambulance arriving 2 hours and 20 minutes after the incident was reported. He received thrombolysis and later suffered a large intracranial bleed before dying at the hospital. Concerns included the grading of acute stroke patients, whether a specific response-time target should be set, and whether additional ambulance resources were needed.

Grenville Wait · Prevention of Future Deaths report View report

24 Jun 2022 Manchester South C. Morris

Grenville Wait fell while shopping, sustained a fractured sternum, and was later found deeply unconscious at home. He died after an ambulance response that was incorrectly coded as category 2 and arrived around 70 minutes after the 999 call; the principal concern was that target ambulance response times were routinely not being met nationally.

Lucas Tyler Pollard · Prevention of Future Deaths report View report

1 Feb 2024 Bedfordshire and Luton S. Cummings

Lucas Tyler Pollard, aged 14, died after sustaining catastrophic injuries in a collision while riding an electric moped on 1 June 2023. Concerns included the failure to dispatch a Critical Care Team promptly, the cancellation of a rapid response vehicle three minutes from the scene under the End of Shift Policy, and the absence of dynamic reassessment despite evidence of his deterioration. The report also raised concern that applying the policy in this way could threaten a patient's life in future situations.

Lynda BLACKMORE · Prevention of Future Deaths report View report

15 Nov 2023 South Wales Central G. Hughes

Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.

Ceriann Richards · Prevention of Future Deaths report View report

1 Mar 2017 South Wales Central A. Barkley

Ceriann Richards was found acutely unwell and suffering seizures at home on 14 August 2016. An ambulance took approximately three hours to convey her to hospital, where she died later that morning. A post-mortem found very high, toxic levels of Venlafaxine, while the principal concern was delay in ambulance despatch linked to hospital handover delays.

Barbara HOLLIS · Prevention of Future Deaths report View report

7 Oct 2022 Norfolk J. Lake

Barbara Hollis underwent a total left knee replacement and became restless, confused and progressively unwell afterwards. Although an ambulance was requested urgently for transfer to a high dependency unit, the agreed transfer pathway was not followed and attendance was delayed; she died in the early hours of 23 February 2022. The concern was that emergency ambulance availability and response delays could result in future deaths while remedial steps were being assessed.

Kathryn Verina Richmond · Prevention of Future Deaths report View report

17 Nov 2017 Dorset R. Griffin

Kathryn Verina Richmond collapsed at home on 21 April 2015, was taken to hospital after delays in ambulance attendance, and died that morning despite lifesaving treatment for a ruptured spleen. The principal concern was that non-staggered ambulance crew shifts led to simultaneous meal breaks, reducing available resources and potentially delaying responses to emergency calls.

Christopher George Connor · Prevention of Future Deaths report View report

12 Nov 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Christopher George Connor had been socialising at a public house before leaving in the early hours and being found collapsed and unresponsive on a pavement near his home. An ambulance took over 1 hour and 15 minutes to arrive, and the principal concern was the delay in ambulance attendance.

Vivienne Greener · Prevention of Future Deaths report View report

18 Dec 2023 North Wales (East and Central) D. Pojur

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

Barbara YOUNG · Prevention of Future Deaths report View report

28 Jan 2022 Gwent C. Saunders

Barbara Young fell downstairs at home, sustained multiple injuries, developed pneumonia after becoming immobile in hospital, and died on 23 July 2021. The principal concern was that an ambulance took approximately three hours to arrive despite information about her severe injuries and reduced consciousness; the report states that it could not confirm whether the delay contributed to her death, but identified an ongoing risk from delays in timely emergency response.

Joan Mary Corcoran · Prevention of Future Deaths report View report

20 Jun 2023 Manchester South A. Mutch

Joan Mary Corcoran suffered an accidental fall, underwent surgery for a fractured neck of femur, and subsequently developed pneumonia, an infected wound and increasing frailty. After becoming unwell with chest pains, she experienced a 1-hour 5-minute delay for a category 2 ambulance response and died in the ambulance from complications of heart failure while being transported to hospital. The substantive concern was that ambulance response delays were significantly outside target times and reflected wider system pressures, including demand for ambulances and delays at A&E departments.

Joseph Leonard Scott Cattle · Prevention of Future Deaths report View report

22 Feb 2024 South Wales Central G. Knox

Joseph Leonard Scott Cattle contacted the Welsh Ambulance Service Trust at 00:44 in a call categorised as requiring an Amber 1 response, followed by two further calls. Paramedics did not attend until approximately 07:20, by which time he was deceased; concerns included the delay in allocating an ambulance, hospital handover delays affecting ambulance availability, and an apparent shortfall in funded ambulances.

Marjorie Joyce Michael · Prevention of Future Deaths report View report

26 Jun 2024 Gwent C. Saunders

Marjorie Joyce Michael fell at a residential home and lay on the floor for over 14 hours while waiting for an ambulance. She was taken to hospital on 4 September 2023 and died on 6 September 2023; the inquest recorded hypostatic pneumonia following the fall and long lie, with her death contributed to by the delayed ambulance response. The report raises concerns about continuing delays in ambulance responses, including delays in releasing emergency ambulances from acute hospitals.