Thelma Radmore
19 Jul 2023 · Coroner Alison Mutch · Manchester South
This report repeats 3 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed ambulance arrival and prolonged Emergency Department wait
“The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available”
2. ambulance crew waiting in corridor
“The wait Mrs [name redacted] experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards”
3. delayed pressure ulcer prevention measures
“In Mrs [name redacted] case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”
This report
“The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Identical hazardConfidence 0.90 · high
Earlier report
“(1) Evidence given at the inquest revealed that there was a delay in Mr. [name redacted] being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into.”
This report
“1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Closely relatedConfidence 0.90 · high
Earlier report
“Evidence was heard that there was a delay in Mrs [name redacted] being transferred from the ambulance to the Emergency Department of the Queen Elizabeth Hospital as there was no space in the hospital”
This report
“The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available.”
Closely relatedConfidence 0.90 · high
This report
“The wait Mrs [name redacted] experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards”
Later report
“there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so”
Responses
2023-0256-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care