Christopher Fields
18 May 2016 · Coroner John Pollard · Manchester South
A similar concern from this report was raised again 6 times later. See the linked reports.
The coroner's concerns
1. vulnerable person left unattended
“why did they leave a vulnerable person in this manner, why did they not await the arrival of the ambulance, why did they not take the witness (female) who was there at the time to a place where she could give them details out of the earshot of the assailant etc., why did they leave an injured and/or intoxicated person in the sole care of another who was also intoxicated, why did they consider it appropriate to accept the view of the injured/intoxicated person as to whether it was safe to leave him”
2. ambulance response delay
“vehicle did not arrive for 2 hours 8 minutes”
3. inaccurate coding leading to missed red response
“algorithms used for coding are not accurate and not fit for purpose”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later report
“NWAS failed to meet target times which are nationally set by the Department of Health”
Closely relatedConfidence 0.85 · high
This report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later report
“The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”
Closely relatedConfidence 0.90 · high
This report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later report
“The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”
Identical hazardConfidence 0.90 · high
This report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later report
“The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
Closely relatedConfidence 0.90 · high
This report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later report
“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Closely relatedConfidence 0.90 · high
This report
“In the event, the vehicle did not arrive for 2 hours 8 minutes.”
Later 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.”
Responses
2016-0194-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.”
2016-0194-Response-by-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
2016-0194-Response-by-NHS-England.pdf ↗· NHS England
Stated action · autumn 2016
“NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the High quality care for all, now and for future generations outcome of previous similar 999 calls as well as the concerns raised by Coroners in Regulation 28 Reports. We anticipate making recommendations in autumn 2016. It is our intention that this review should improve the service provided and clinical outcomes for future patients contacting the 9”
2016-0194-Response-by-North-West-Ambulance-Service.pdf ↗· North West Ambulance Service
Stated action
“NWAS is currently exploring better ways to minimise lengthy waits during high demand periods and has also secured funding for 400 additional frontline staff and 60 new vehicles which | hope will assist in alleviating some of these pressures.”