Henry Willems
21 Oct 2024 · Coroner David Reid · Worcestershire
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. delayed ambulance response to Category 2 case
“In the early hours of 12.10.23 Mr. [name redacted], who had been unwell with gastritis over the preceding 48 hours, collapsed at his home in Malvern. His family called the emergency services, and paramedics attended him at home, but he was confirmed deceased a short time later. Paramedics had been unable to attend Mr. [name redacted]' address within the mean target response time for a Category 2 case because ambulances were experiencing significant delays in handing their patients over to staff at hospital”
2. failure to meet Category 2 response time
“Mr. [name redacted] would probably have survived this episode, and would not have died when he did, had paramedics been able to attend his home address within the applicable 18 minute mean response time”
3. operational surge causing unmet response time targets
“The Trust was unable to meet the applicable mean and 90th percentile response times, because at the time of these events, it was operating at Emergency and Urgent Surge Level 4 ( the highest level which can be applied ). The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“under the Department of Health's Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases”
This report
“Mr. [name redacted]' case was correctly assigned a Category 2 disposition, for which the mean response time is 18 minutes, and the 90th percentile response time is 40 minutes;”
Identical hazardConfidence 0.90 · high
Earlier report
“if hospital handover delays didn't exist they would be likely to be meeting their response targets as they did before hospital delays became chronic”
This report
“The Trust had over 200 outstanding incidents, of which 31 were other Category 2 cases, and 50% of their vehicles were being delayed at hospitals within the region for anything between 189 minutes and 441 minutes.”