Christopher Williams
31 May 2019 · Coroner Yvonne Blake · Norfolk
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed ambulance arrival
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines”
2. failure to escalate condition
“The failure by the call handler to both escalate Mr [name redacted] worsening condition and her incorrect use of the haemorrhage algorithm”
3. ambulance boarding delay
“When the ambulance transported Mr [name redacted] to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP”
4. communication failure risk
“this failure in communication is one which | feel places other patients at risk of death and is unacceptable”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“Consistently high levels of outstanding emergency calls and waiting times that far exceed the service's own target response times are likely to put lives at risk.”
This report
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Closely relatedConfidence 0.80 · moderate
This report
“The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines.”
Later report
“There were no emergency ambulances available to assign to this call due to high call demand.”
Responses
2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust.pdf ↗· East of England Ambulance Service
Stated action
“the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls”