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William George Irvin Watson · Prevention of Future Deaths report View report

19 Jul 2018 Cornwall and Isles of Scilly A. Cox

William George Irvin Watson was admitted with worsening angina, underwent triple coronary artery bypass surgery, and experienced post-operative complications including an infected sternal wound. He died after difficulties and delays in emergency, high-dependency and non-emergency patient transfers. The principal concerns were inadequate ambulance and patient-transport resources, performance gaps, and the potential risk of avoidable deaths or deterioration when transfers are delayed.

Amanda Jane GAINFORD · Prevention of Future Deaths report View report

24 Oct 2024 Liverpool and the Wirral K. Roberts

Amanda Jane GAINFORD, aged 52, sustained abdominal injuries while detained in a mental health ward and later died at Aintree Hospital on 4 November 2022 from multiorgan failure due to splenic laceration and liver cirrhosis. The inquest identified missed opportunities to provide intravenous fluids and call an ambulance earlier while she had prolonged low blood pressure. It also raised concern that clinicians were not sufficiently aware of the ability to challenge ambulance call categorisation and request a clinical review from the ambulance service.

Christopher Williams · Prevention of Future Deaths report View report

31 May 2019 Norfolk Y. Blake

Christopher Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.

Darren James Powney · Prevention of Future Deaths report View report

10 Nov 2017 Sunderland D. Winters

Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.

Lilly Baxandall · Prevention of Future Deaths report View report

17 May 2017 North Wales (East and Central) J. Gittins

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

ROBERT ANDREW PROWSE · Prevention of Future Deaths report View report

25 Mar 2024 Cornwall and Isles of Scilly G. Davies

Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.

Claire Nicole Briggs · Prevention of Future Deaths report View report

8 Dec 2023 Manchester South A. Farrow

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

Rosie Catherine YOUNG · Prevention of Future Deaths report View report

16 Feb 2024 Worcestershire D. Reid

Rosie Catherine YOUNG died on 8 November 2021 after sustaining a traumatic brain injury when she stepped from the rear door of a moving ambulance while being transported to a psychiatric unit. The inquest identified concerns about failures to record and communicate her previous incidents of jumping from moving vehicles, inadequate risk assessment and transport arrangements, and insufficient staff awareness and training regarding the Mental Health Act Transportation Policy.

Anthony Offord · Prevention of Future Deaths report View report

8 Sep 2014 South Yorkshire (Western) P. Dorries

Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.

Liam Paul McCarlie · Prevention of Future Deaths report View report

24 Jun 2024 Northamptonshire J. Dixey

Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.

Aidan David Ridley · Prevention of Future Deaths report View report

9 Apr 2019 Wiltshire and Swindon I. Singleton

Aidan David Ridley was struck by a car while crossing a road on 12 February 2016 and died three days later from hypoxic brain injury caused by how he landed, which obstructed his airway. Concerns included police call-handler advice not to turn him over, insufficient direction to seek ambulance advice or defer to medically trained bystanders, and inadequate call-handler training, guidance and supervision.

Andrew Stephen Finlay · Prevention of Future Deaths report View report

26 Jan 2018 Sunderland D. Winter

Andrew Stephen Finlay, aged 54, collapsed at home on 13 December 2016 and died there the following day. Although expert evidence indicated that the delay in dispatching and arriving with an ambulance did not affect the outcome, concerns remained about delays in emergency ambulance responses, including ongoing paramedic vacancies.

Raphael Jeffery Gill · Prevention of Future Deaths report View report

27 Apr 2022 South London J. Landau

Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.

Finlay Stuart Ian FINLAYSON · Prevention of Future Deaths report View report

22 Mar 2024 East Sussex L. Bradford

Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.

Alice Olivia CLARK · Prevention of Future Deaths report View report

24 Oct 2024 North West Kent R. Hatch

Alice Olivia Clark died after being trapped in a SECAMB ambulance involved in a road traffic collision on the A21 on 5 January 2022. Concerns included complaints about unsafe driving that were not appropriately dealt with, the absence of a formal complaint procedure, and the way ambulance driving standards were assessed.

Colonel John Frederick Codd · Prevention of Future Deaths report View report

29 Jul 2024 Cornwall and Isles of Scilly A. Cox

Colonel John Frederick Codd fell while exiting a taxi after a GP appointment and was taken by ambulance to hospital, where he waited outside for approximately 4 hours and 40 minutes before being admitted to the Emergency Department. He was later found in cardiac arrest and could not be resuscitated; the inquest recorded the cause of death as a massive rectus sheath haematoma and severe coronary artery atherosclerosis. The principal concerns were delays in hospital admission and ongoing Emergency Department crowding, which had the potential to affect future patient care.

Clara Ellen Freeman · Prevention of Future Deaths report View report

26 Mar 2021 Plymouth, Torbay and South Devon S. Covell

Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.

Rajesh Parkash · Prevention of Future Deaths report View report

8 May 2014 Surrey R. Travers

Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.

Mrs Elizabeth Glen Self · Prevention of Future Deaths report View report

29 Oct 2019 South Yorkshire (Western) C. Dorries

Mrs Elizabeth Glen Self was admitted to hospital following a heart attack and later suffered a serious fall after becoming entangled in a line attached to her left leg. Injuries were not immediately recognised, and there were delays of more than thirteen hours in dealing with requested x-rays and a CT scan. The concerns included inadequate training in making x-ray requests, a possible breakdown in communications, and systems that allowed imaging requests to remain unresolved for hours.

Derek Shaw · Prevention of Future Deaths report View report

11 Nov 2022 Suffolk C. Wood

Derek Shaw fell at home and became unwell the following morning, but an ambulance was delayed and he suffered a cardiac arrest before the crew arrived. The inquest heard that earlier ambulance attendance was likely to have meant he would not have died, and that ambulance availability was affected by a complex capacity problem involving local NHS trusts.