72-year-old grandmother dies in agony after waiting ALL NIGHT for ambulance that never arrived as coroner blasts ‘waste of time’

A 72-year-old grandmother died after waiting all night for an ambulance despite being classed as high priority, an inquest heard.

A coroner has raised concerns about the risk of ‘future deaths’ at the ambulance service after Susan Dear, from Berkshire, was left unattended for seven hours after her family first called 999.

Coroner Hannah Godfrey wrote a report to NHS England titled ‘Preventing Future Deaths’ due to concerns about response times for the South Central Ambulance Service.

Ms. Dear’s family called for emergency care at 22.20 on January 3, 2023, after she started experiencing abdominal pain. 999 calls were prioritized in category 3; This meant that an ambulance was expected to arrive at the scene within 120 minutes.

However, the investigation heard that there was a backlog of 48 patients waiting for an ambulance at that time, seven of whom were waiting for category 2 ambulances with the longest waiting time of 1 hour and 12 minutes, and 19 patients were waiting for category 3 ambulances with the longest waiting time of 1 hour and 12 minutes. waiting time is 7 hours 55 minutes.

As Ms Dear’s condition worsened, her family called 999 a second time, hoping for an ambulance to arrive immediately at their Berkshire property.

The call, made at 2.32am on January 4, has now been prioritized as category 2, making it a higher priority and the ambulance is expected to arrive at the scene within 40 minutes.

There were currently 37 patients waiting for an ambulance. While 9 patients were waiting for the Category 2 ambulance with the longest waiting time of 5 hours and 53 minutes, 26 patients were waiting for the Category 3 ambulance with the longest waiting time of 14 hours and 39 minutes.

View of parked South Central Ambulance Service ambulances

Although Ms. Dear waited for another two and a half hours due to her condition deteriorating, no ambulance could attend to her.

At around 5am, his family decided they couldn’t wait any longer and took him to hospital, where he was confirmed dead at 6.02am.

The coroner’s conclusion does not establish that ambulance delays contributed to Ms Dear’s death, but does indicate that death was due to natural causes – pulmonary embolism due to underlying deep vein thrombosis.

However, the coroner felt the evidence at the hearing raised concerns about the risks of future deaths if action was not taken.

The area was at Operational Pressure Escalation Level (Opel) four when the second 999 call was made on behalf of Ms Dear.

This indicates ‘extreme pressure’ on resources.

An internal investigation by the ambulance service found there was no ‘missed opportunity’ to send an ambulance during the time Ms Dear was waiting for an ambulance because there were no ambulances available.

The report, which recommended measures to be taken to ‘prevent future deaths’, stated that on the night of January 3-4, ‘patients’ lives were put at risk due to the lack of ambulances to meet the demand level of SCAS, and this caused serious delays’. ‘Ambulance response times are well outside expected national standards’.

The inquest was heard at Berkshire Coroner’s Court, Reading Town Hall.

The coroner concluded Ms Dear died of natural causes, namely pulmonary embolism due to underlying deep vein thrombosis, but expressed concern about ‘chronic’ shortages and delays in the ambulance service.

However, the coroner found that this was not an isolated or ‘unprecedented’ problem but ‘reflects a picture of a chronic situation where there is an ongoing risk that the demand for emergency ambulances will exceed resources and SCAS cannot reassure me of this’. It was a resolved situation’.

The inquest into Ms Dear’s death began on 23 May this year and concluded on 9 September.

The report also examined the service’s ‘chronic understaffing’ nationally and highlighted handover delays at the Royal Berkshire Hospital and Wexham Park Hospital; these delays prevented ambulances from responding to calls.

It reads: ‘SCAS’s service was operating below the planned number of staff for that night (despite the service taking all reasonable steps to meet requirements) due to the service being chronically understaffed due to recruitment and retention issues with paramedics and other emergency response staff. that the investigation heard was problems at the national level.

‘Handover delays at the Royal Berkshire Hospital and Wexham Park Hospital were identified as a significant root cause of the problem (due to ambulance staff being delayed at the hospital due to patients being unable to be admitted to Accident and Emergency due to other patients being unable to be admitted). will be admitted to the wards until beds become available).

‘This was an issue that required improvement nationally, with changes to the social care system to make it easier for patients requiring community care to be discharged from wards back into the community.’

The coroner also found that resources were being ‘wasted’ due to the ‘ignorance’ of some members of the public who called 999 or opted for emergency care when it was not available, putting further pressure on the NHS.

NHS England’s response to the coroner’s report expressed ‘deep condolences’ to Ms Dear’s family and acknowledged the ‘significant pressures on all NHS services, including ambulances’, prioritizing improvements to Category 2 response times.

Their response was: ‘Despite significant challenges, including unprecedented industrial action and higher than expected demand, there has been a marked improvement in 2023/24; More than 2.5 million people completed their A&E treatment within 4 hours compared to 2022/23.

‘The study also focused on the need to increase ambulance capacity by increasing the workforce, improving flow in hospitals and reducing handover delays, accelerating hospital discharges and expanding new services in the community; all of which support improved patient flow.

‘My regional colleagues in the South East have contacted SCAS regarding the concerns raised in your Report. A number of local initiatives and improvement programs are being undertaken to improve their performance and enable the Trust to provide the best care to its patients. They say they aim to employ an additional 100 paramedics this year through an international recruitment programme, and have purchased additional ambulances through the national procurement framework.’

South Central Ambulance Service operations manager Mark Ainsworth also expressed the service’s ‘sincere condolences to Ms Dear’s family and loved ones’.

He explained: ‘As noted at the time of the emergency call in January 2023 and in the Coroner’s report, there was no opportunity to send an ambulance to Ms Dear earlier due to the great demand on our emergency service. Resources available at the time were inadequate, with significant numbers of ambulance crews waiting to deliver patients at the Royal Berkshire and Wexham Park Hospitals.

‘Since January 2023 the trust has embarked on a number of improvement programmes, including the recruitment of more paramedics, improving the ambulance fleet and implementing a number of operational efficiencies such as prompt delivery of the hospital following specific, accepted request or pressure with our hospital partners. trigger points are met.

‘We will also shortly be introducing a trust-wide response policy that ensures ambulance crews are not delayed more than 45 minutes when arriving at hospital with a patient.

‘Recognizing that demand across the NHS is at unprecedented levels, the trust continues to work with healthcare partners to minimize the impact of hospital handover delays on our ability to respond to patients in the community, and the senior management team remains fully focused. Delivering all aspects of the trust’s operational modernization and transformation programme.

‘This program will see the delivery of a range of linked projects between 2024-29 to ensure the trust can deliver high quality care, achieve performance standards and support staff wellbeing whilst operating within the allocated budget.’