Geoffery Hoad
13 Sept 2023 · Coroner Jacqueline Lake · Norfolk
This report repeats 4 earlier warnings, and was raised again 5 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance response
“The ambulance service was called on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours.”
2. delayed ambulance response
“The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”
3. delayed ambulance response
“The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.”
4. delayed ambulance response
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
5. delayed ambulance response
“The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”
6. ongoing ambulance response delays
“Despite the steps being taken by the EEAST, considerable delays in attending to calls continue.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive.”
This report
“The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”
Closely relatedConfidence 0.85 · high
Earlier 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.”
This report
“The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours.”
Identical hazardConfidence 0.90 · high
Earlier report
“they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend”
This report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours.”
Identical hazardConfidence 0.90 · high
Earlier report
“notwithstanding her age and frailty [the deceased] had to wait over 5 hours for an ambulance. This was due to the demands on the North West Ambulance Service on the day in question.”
This report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
Closely relatedConfidence 0.90 · high
This report
“Evidence was heard as to the very high call demand overnight on 6t h and ih August 2022 and with regard to the number of ambulances waiting at Hospitals in the region to hand over patients”
Later report
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.”
Identical hazardConfidence 0.90 · high
This report
“The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes.”
Later report
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Closely relatedConfidence 0.85 · high
This report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
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 0.85 · high
This report
“Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours.”
Later report
“However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr [name redacted].”
Closely relatedConfidence 0.90 · high
This report
“The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call.”
Later report
“An ambulance should have reached [the deceased] within two hours but it took five and half.”
Responses
2023-0327-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · this year
“we published our 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year”
2023-0327-Response-from-East-of-England-Ambulance-Service-NHS-Trust.pdf ↗· East of England Ambulance Service NHS Trust
Stated action · March 2024
“Additional recruitment with the aim for there to be over 300 more frontline clinicians in place by March 2024”