Bernard Compton

“The inquest heard evidence that the delays in the Emergency were due to demand and were not unusual. It was recognised that the delays presented a risk and steps had been taken to try to mitigate them but there was no evidence that particularly during the night hours any one person had oversight of patients or that there was a system to ensure effective management of patients. The situation Mr [name redacted] experienced was a direct consequence of the lack of oversight and system.”

“It was unclear what system was in place to effectively ensure urgent blood results were acted upon immediately. The inquest was told the lab would telephone through on some occasions. It was unclear what the protocol was and who had oversight of it.”

“The ECG told the clinician that there was a likely MI. It was entirely unclear why that was not acted on. The clinician did ask for a repeat within 30 minutes. That did not happen. There was no evidence of a system to ensure tests were repeated and directed and how that was monitored.”

“When Mr [name redacted] made his first call to NWAS he was exhibiting symptoms consistent with an ongoing MI. However the questioning via the algorithm did not pick that up. NWAS were unable to clarify why that was the case. A call from someone actively having a MI was therefore categorised as a category 3 despite the time critical nature of the condition.”

“Demand on NWAS meant that even though they knew he had been diagnosed as being in the throes of a MI they could not get an ambulance to him in less than 45 minutes due to demand on their services.”

“The consequence of delay in assessing and treating Mr [name redacted] was that an opportunity to treat him effectively was not available to clinicians.”