Graham Whiteley
30 Jan 2025 · Coroner Vanessa McKinlay · Somerset
The coroner's concerns
1. delayed category 2 ambulance response
“The 999 call to the ambulance service was received at 14.24 hours. The Emergency Medical Dispatcher was informed that Mr [name redacted] had fallen, had banged his head, was bleeding and was barely conscious. This generated a category 2 response requirement.”
2. high incident queue backlog
“At 15.03 hours there were 107 incidents awaiting allocation across the ambulance Trust area, including 21 in the Bravo patch where Mr [name redacted] incident occurred.”
3. handover delays at acute hospitals
“The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary).”
4. significant lost ambulance shift capacity
“The handover delays meant that there were over 84 hours of ambulance time lost to handovers. This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays.”
5. prolonged expected arrival time
“An ambulance was allocated to Mr [name redacted] at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr [name redacted] ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call.”
6. police intervention overriding ambulance dispatch
“In the event, Avon and Somerset Police conveyed Mr [name redacted] to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down.”