Michael Clarke
3 May 2024 · Coroner Alison Mutch · Manchester South
This report repeats 2 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. ambulance response delay
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour”
2. lack of sepsis trigger mechanism
“no specific sepsis trigger questions on the ambulance pathway”
3. delayed antibiotic administration
“antibiotics need to commence as a priority.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
This report
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Identical hazardConfidence 0.90 · high
Earlier report
“The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service”
This report
“The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour”
Identical hazardConfidence 0.90 · high
This report
“The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour.”
Later report
“The court heard evidence to the effect that, notwithstanding the national target for Category 3 999 calls of 9 out of 10 responses within 120 minutes, the anticipated wait for a Category 3 ambulance on 1st June 2024 was around 3 hours and 15 minutes.”
Closely relatedConfidence 0.90 · high
This report
“due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour”
Later report
“An ambulance resource arrived around 10 hours from [the deceased]'s first call (to 111 services), and 8 1⁄2 hours after the ambulance service categorised this as a call requiring attendance within 2 hours.”
Closely relatedConfidence 0.90 · high
This report
“The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway.”
Later report
“The lack of a sepsis algorithm pathway to assist the emergency medical advisor (EMA) during 111/999 calls”
Responses
2024-0245-Response-from-NHS-England-and-NHS-GMIC.pdf ↗· NHS England
Stated action · 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England has prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, which was published in January 2023. The plan outlined key”