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Henry Michael WILLEMS · Prevention of Future Deaths report View report

21 Oct 2024 Worcestershire D. Reid

Henry Michael WILLEMS collapsed at home in Malvern in the early hours of 12 October 2023 after being unwell with gastritis for 48 hours and was confirmed deceased after paramedics attended. The report identified concern that the ambulance response was substantially delayed, with expert evidence that he would probably have survived if paramedics had attended within the applicable 18-minute mean response time.

Dorothy Margaret Hoyberg · Prevention of Future Deaths report View report

14 Jan 2026 Inner North London M. Lee

Dorothy Margaret Hoyberg called emergency services with worsening severe leg, abdominal and back pain and was assessed as requiring a Category 3 ambulance response. The ambulance arrived five and a half hours later, and she was found deceased; post-mortem toxicology showed elevated morphine and methadone levels, and the inquest determined that her death was drug related. The principal concern was the prolonged ambulance delay during extreme pressure on ambulance services, with insufficient capacity for regular welfare call-backs.

Gina Marie BYWATER · Prevention of Future Deaths report View report

7 Nov 2023 Suffolk N. Parsley

Gina Marie Bywater became unwell with vomiting, shortness of breath and later chest pains, but an ambulance was not available for nearly 10 hours despite repeated 999 calls. She was found in cardiac arrest and subsequently died from a heart attack. The principal concern was the continuing lack of sufficient ambulance resources in Suffolk and the wider East of England, resulting in delays that the report states contributed to her death.

PATRICIA ANNE VAN DER EYKEN · Prevention of Future Deaths report View report

25 Mar 2024 Cornwall and Isles of Scilly G. Davies

Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by preventing lifesaving treatment.

Madeline Constance Staples · Prevention of Future Deaths report View report

11 Feb 2019 North Wales (East and Central) J. Gittins

Madeline Constance Staples, an 86-year-old woman, suffered an unwitnessed fall at her care home on 6 April 2018, sustaining fractures to both legs. Delays in obtaining ambulance assistance and transporting her to hospital meant she remained in pain for several hours. The report raised concerns about repeated unacceptable delays linked to emergency department handovers and unavailable ambulance resources, placing patients’ lives at risk.

Sylvia Eileen Evans · Prevention of Future Deaths report View report

20 May 2024 Gwent C. Saunders

Sylvia Eileen Evans sustained an accidental leg wound at home on 5 September 2023, causing severe haemorrhage, and died at home the following day. She called for an ambulance at 22:56, but the call ended abruptly before the nature of her injuries was conveyed. An ambulance arrived at 07:45, almost 8 hours and 49 minutes after the call was registered, and the report identifies hospital handover delay as contributing in part to the delay.

Thelma Mary Radmore · Prevention of Future Deaths report View report

19 Jul 2023 Manchester South A. Mutch

Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.

Maureen Woods · Prevention of Future Deaths report View report

24 Jul 2019 Nottinghamshire L. Bower

Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.

Rebecca Anne Evans · Prevention of Future Deaths report View report

14 Mar 2017 North Wales (East and Central) J. Gittins

Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and ambulance availability.

Bernard Compton · Prevention of Future Deaths report View report

5 Jun 2024 Manchester South A. Mutch

Bernard Compton developed symptoms of a myocardial infarction, but delays in ambulance response, ECG interpretation, triage, blood-result review and clinical assessment meant that the optimum window for intervention had passed. He later suffered a left ventricular rupture and died on 19 October 2023. The concerns included inadequate oversight of patients and urgent results, unclear systems for repeating and acting on tests, and demand-related delays in ambulance and emergency care.

Michael Clarke · Prevention of Future Deaths report View report

3 May 2024 Manchester South A. Mutch

Michael Clarke, who had multiple underlying health conditions including end stage renal failure, developed suspected urosepsis after a cystoscopy and died in hospital on 30 July 2023. The report raised concerns about delays in category 3 ambulance responses, the categorisation of a call where sepsis was suspected, and the absence of specific sepsis trigger questions on the ambulance pathway.

Peter Andrew Connelly · Prevention of Future Deaths report View report

7 Nov 2019 North Wales (East and Central) J. Gittins

Peter Andrew Connelly was transferred to hospital on 19 February 2018, waited several hours for admission and medical examination, was diagnosed with acute pancreatitis, and died on 20 February 2018. The principal concern was continuing extreme pressure and delays in emergency department admission and treatment, which the report stated could place patients’ lives at risk and lead to preventable deaths; the delay was accepted not to have caused or contributed to Mr Connelly’s death.

Gwynne SAMUEL · Prevention of Future Deaths report View report

17 Jun 2022 Gwent C. Saunders

Gwynne Samuel, a 95-year-old man who lived alone, fell at home and waited approximately 12 hours for an ambulance before being taken to hospital. He developed an acute kidney injury attributed to the prolonged lie, which delayed hip surgery; he subsequently developed a chest infection and died from pneumonia. The principal concern was the ambulance response time for a patient categorised as Amber 2 and whether the clinical effects of a prolonged lie in an elderly person were adequately considered during categorisation.

Keith Hopwood · Prevention of Future Deaths report View report

15 Jun 2022 Manchester South A. Mutch

Keith Hopwood fainted and felt very unwell before calling an ambulance, reporting chest pain during a later call. He was found unresponsive at home and could not be resuscitated; the medical cause of death was myocardial infarction due to stenotic coronary artery atheroma. The concerns included delays and resource pressures in the ambulance service, failure to upgrade the call category, limitations in the call-handling algorithm, the use of a private ambulance not equipped to deal with a cardiac patient, and the handling of a disconnected call when he was alone.

Alf REWIN · Prevention of Future Deaths report View report

7 Oct 2019 Buckinghamshire C. Butler

Alf Rewin died at Wexham Park Hospital on 22 November 2018 after taking an overdose of Quetiapine, Methylphenidate and Duloxetine and becoming unresponsive before arrival. The principal concern was that overdose cases could receive a Category 3 ambulance response with a target of up to 120 minutes, despite the risk of unconsciousness, cardiac arrest or other potentially fatal events requiring earlier attendance.

Peter COATES · Prevention of Future Deaths report View report

23 Mar 2026 Teesside and Hartlepool P. Appleton

Peter Coates, who had very severe COPD and relied on mains-powered respiratory equipment, died at home after an unplanned electrical power failure stopped that equipment. The report identifies delays in ambulance attendance and a concern that the ambulance response categories have a gap for patients who are not in cardiac or respiratory arrest but require an immediate response, particularly when alone and unable to update the ambulance service.

Evelyn Mary Dutton · Prevention of Future Deaths report View report

19 Jul 2023 Manchester South A. Mutch

Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.

Mary Elizabeth Jones · Prevention of Future Deaths report View report

10 Jul 2023 North West Wales K. Robertson

Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.

Helen Jayne SHEATH · Prevention of Future Deaths report View report

27 Jan 2020 Bedfordshire and Luton E. Whitting

Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.

Christopher Ivan HART · Prevention of Future Deaths report View report

9 Nov 2023 Suffolk N. Parsley

Christopher Hart became unwell at home and an ambulance was requested, but no ambulance was immediately available because of high service demand and hospital off-loading delays. He was later found unresponsive and could not be resuscitated; the report states that his cardiac condition caused his death and that the ambulance delay directly contributed to it. The principal concern was continuing and regular ambulance non-availability in Suffolk and the wider East of England region, with insufficient ambulance resources potentially leading to future loss of life.