Pensioner died ‘alone and confused’ after 14-hour ambulance wait …
A 73-year-old man waited nearly 14 hours for paramedics and died in hospital after an ambulance was not sent out to him on a previous day following a fall.
The man, Keith Nielsen, who was on the anti-coagulant medication Warfarin, had called 999 having had a fall at home, telling call handlers he was alone, had hit his head and could not remember the last twelve hours. He called at 05:33am on 21 March 2022.
But according to a coroner’s report, his call was marked as “no send” and he was advised to make his own way to hospital.
At 4:18pm his GP contacted Mr Nielsen by phone in response to an earlier online request for a routine appointment. The GP was not made aware of the fall or the head injury but given that Mr Nielsen was confused during the call and was on Warfarin he asked his receptionist to call an ambulance. At 5:37pm a receptionist called and requested an ambulance within two hours.
While the call was made at 5:37pm on March 21, 2022, the ambulance did not arrive until 07:22am the following day, when the man was found to be unresponsive.
Mr Nielsen was admitted to East Surrey Hospital but died there on 23 March 2022 after being diagnosed with a traumatic brain injury.
These are the findings of the assistant coroner for Surrey, Anna Crawford, in a Prevention of Future Deaths report sent to SECAMB’s chief executive officer and to the Secretary of State for Health and Social Care, Steve Barclay.
Miss Crawford’s report, published in June, highlighted the inquest’s findings that if an ambulance had been sent after the man’s early morning call for an ambulance after his fall, he “would have survived”.
A response from the interim executive director of quality and nursing on behalf the ambulance service’s chief executive officer said they were “saddened” to hear of Mr Nielsen’s death and offered sincere condolences to his family and friends.
They said population growth in the south east, demographic shifts and an ageing population were factors which all contributed to more complex calls, needing additional resource and clinical expertise. They said they a new trust strategy is in development.
The response added: “SECAmb will continue to work with partners on local and national programmes of work to meet the functional demand and clinical level of support that the public expects.”
At the time of his call, SECAMB was operating at level 4 of its surge management plan, when demand was “significantly outstripping available resources”, meaning calls could not be responded to within target timeframes.
During such times, the service operates a “no send policy” during which certain patients are asked to make their own way to hospital unless they are unable or refuse to do so.
In these cases, calls are subject to a clinical review and a decision is taken as to whether an ambulance should be sent out to the patient.
Miss Crawford said: “The court found that a clinical review should have taken place which would have resulted in a category 3 ambulance being assigned to [him].”
But on the delay of an ambulance arriving after the second call, the inquest found: “Whilst the length of that delay is clearly a matter of concern, it did not materially contribute to [his] death.”
The assistant coroner said there was “a risk of a future re-occurrence” of such a situation, given that SECAMB is “regularly operating” at stage 4 of its surge management plan.
SECAMB said the current pattern of demand was out of alignment with 2017-18 figures it was commissioned for, and though rota patterns had been changed, “additional staffing numbers are required to meet the change in demand”.
The service response said: “To support the improvement needed not only in the ambulance service, but also across other health and care providers, system solutions are required so that patient care and flow can be provided in not only the best way possible for the patient, but to also maximise efficiencies across integrated care systems.”
Three areas specified as a focus by NHS[2] England were call handling, mean response times of a maximum of 30 minutes for certain calls by the end of the financial year and hospital handover times.
No response from the health secretary had been published at the time of writing.
References
- ^ ‘Missed’ home visits and ‘rushed’ staff lead to special measures for Surrey care service (www.getsurrey.co.uk)
- ^ NHS (www.getsurrey.co.uk)