Donna Smith
22 Jan 2024 · Coroner Clare Bailey · Teesside and Hartlepool
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. failure to detect worsening condition
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
2. insufficient detection robustness
“The methods of detecting worsening conditions in existing category 2 calls are not sufficiently robust (dispatch clinician and numerous call condition).”
3. response time breach
“The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“the reasons for the delay of the ambulance arrival include severe demand and shortages in the division.”
This report
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Closely relatedConfidence 0.85 · high
Earlier report
“Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at [the deceased]'s side.”
This report
“The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1.”
Closely relatedConfidence 0.85 · high
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
This report
“The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.”