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Dennis John William KING · Prevention of Future Deaths report View report

15 Jan 2024 Suffolk D. Stewart

Dennis John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.

Mr Gordon Gillott · Prevention of Future Deaths report View report

4 Feb 2020 Derby and Derbyshire E. Serrano

Mr Gordon Gillott presented with a ruptured abdominal aneurysm, underwent surgery, and later died from sepsis secondary to a bowel perforation. The principal concern was a substantial ambulance delay in transferring him, caused by resourcing issues, creating a risk of future deaths among acutely ill patients requiring urgent transfers.

Susan Dear · Prevention of Future Deaths report View report

20 Sep 2024 Berkshire H. Godfrey

Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.

Emlyn Victor Roberts · Prevention of Future Deaths report View report

6 Jul 2023 North Wales (East and Central) J. Gittins

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

John Trevor WINSWORTH · Prevention of Future Deaths report View report

29 Sep 2023 Norfolk J. Lake

John Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to calls.

Lisa CODLING · Prevention of Future Deaths report View report

19 Feb 2021 Brighton and Hove V. Hamilton-Deeley

Lisa Codling, aged 49, took an overdose of paracetamol on 5 September 2020 after an emotionally charged encounter, and her death was confirmed by paramedics that evening. The principal concern was that the ambulance took 3 hours and 10 minutes to arrive; the inquest found that earlier arrival might have allowed ICU treatment that could have changed the outcome.

Patricia Grace Eileen Green · Prevention of Future Deaths report View report

4 Feb 2023 Manchester South A. Mutch

Patricia Grace Eileen Green had an accidental fall at home and remained prone on the floor for nine hours while waiting for an ambulance. She deteriorated, including in her breathing, and later died in hospital from COVID-19 pneumonia, with the investigation noting the fall and prolonged time on the floor as contributing factors. Concerns included delays in ambulance response and emergency department assessment, linked to shortages, high demand and delays transferring patients from emergency departments.

Frederick Douglas Pring · Prevention of Future Deaths report View report

21 Jan 2014 North Wales (East and Central) J. Gittins

Frederick Douglas Pring experienced chest pains, but no ambulance was available after his first emergency call because of delays handing over patients at hospitals and ambulance crews being on rest breaks. He died at home on 21 March 2013 before an ambulance arrived; a post-mortem identified ischaemic heart disease and severe chronic obstructive pulmonary disease. The principal concern was that delays in patient handovers at Emergency Departments left patients waiting in ambulances and made ambulance resources unavailable for other calls.

William Oliver · Prevention of Future Deaths report View report

12 Sep 2019 Manchester North J. Kearsley

William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.

Celia Sanderson · Prevention of Future Deaths report View report

10 Feb 2023 Manchester South A. Mutch

Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report View report

14 Aug 2019 Cheshire H. Westerman

Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.

Kyriacos Athanasis · Prevention of Future Deaths report View report

6 Jan 2022 Norfolk C. Wood

Kyriacos Athanasis, an 88-year-old man with frailty and several medical conditions, fell down stairs and sustained an unstable cervical spine fracture. Delays transferring him from an ambulance and diagnosing the fracture were followed by pneumonia, and he died after deteriorating. The principal concerns were emergency department overcrowding, insufficient ambulance patient safety checks, delayed diagnosis and treatment, and resulting risks to patients awaiting ambulance transfer or care.

Paul Anthony Burke · Prevention of Future Deaths report View report

2 May 2025 Hertfordshire J. Howell

Paul Anthony Burke, aged 41, developed worsening shortness of breath on 19 December 2022 but did not receive an ambulance despite repeated category 2 calls, and was taken to hospital by family. He was later diagnosed with Type 2 Respiratory Failure, deteriorated despite non-invasive ventilation, and died at 07:44hrs on 22 December 2022. The principal concern was the continuing risk of future deaths from delays in providing pre-hospital emergency care, which appeared to be multi-factorial.

Anton Kusz · Prevention of Future Deaths report View report

27 Apr 2017 South Wales Central A. Barkley

Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.

Colin Wiles · Prevention of Future Deaths report View report

24 Nov 2024 East Riding and Hull S. Robinson

Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

David John Morganti and 3 others · Prevention of Future Deaths report View report

10 Nov 2022 Cornwall and Isles of Scilly A. Cox

The report concerns several deaths involving delays in ambulance attendance and/or admission to Royal Cornwall Hospital, including deaths after falls, head injuries and a stroke. The principal concerns are the ongoing delays caused by ambulances being held at the hospital, limited intermediate and social care capacity, and the risk that unsafe or inadequately staffed discharge arrangements may worsen patients’ health and lead to readmission.

Michael John VINCENT · Prevention of Future Deaths report View report

7 Nov 2023 Bedfordshire and Luton S. Cummings

Michael John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.

Yunus Hoque · Prevention of Future Deaths report View report

26 Feb 2026 Manchester South B. Myers

Yunus Hoque, aged 13, became increasingly unwell with a viral infection and Group A streptococcal infection before suffering respiratory and cardiac arrest after a delayed ambulance response. The principal concern was that, when an ambulance response is significantly delayed beyond the time indicated to the caller, there was no follow-up communication to reassess the patient, inform the caller of the delay, or identify deterioration requiring a more urgent response.

Brian GARRICK · Prevention of Future Deaths report View report

3 Jun 2025 Devon, Plymouth and Torbay S. Covell

Brian Garrick experienced severe chest pain on 10 August 2022 and was taken to hospital after a substantial ambulance response delay. He suffered a cardiac arrest during a procedure and was pronounced deceased at 1145. The principal concern was that severe delays in patient handovers at acute hospitals were affecting ambulance response times and timely treatment for acute illnesses.

Heather Louise Parkhill · Prevention of Future Deaths report View report

2 Feb 2026 North Wales (East and Central) J. Gittens

Heather Louise Parkhill died at home on 8 April 2025 after more than fifteen hours had elapsed since the first 999 call for assistance. Multiple calls did not result in an ambulance response because of resource issues, and an earlier response was considered likely to have prevented the death. The principal concerns were persistent ambulance resource shortages and delays in emergency response, with the report stating that lives continued to be put at risk.