On 16 February 2022 an investigation commenced into the death of Roy Middleton, aged 85 years. The investigation concluded with an inquest heard on 16 November 2022. The Coroner returned a narrative conclusion.

On 9 February 2022 Roy Middleton fell at his home address in Sheffield and struck his head. A carer requested emergency medical assistance at 16:41 advising the Yorkshire Ambulance Service that he was taking warfarin; he had a large cut to his head and there was ‘quite a lot’ of bleeding. The call was allocated a category 3 response time with a 90% centile target of 2 hours. A second call was made to the Yorkshire Ambulance Service by a carer at 19:52 requesting an update on the arrival of an ambulance and expressing concern Mr Middleton was concussed. The call was allocated a category 3 response time. At 20:30 a paramedic from the clinical hub at Yorkshire Ambulance Service called and spoke to Mr Middleton’s son who described a 4-inch laceration to the back of Mr Middleton’s head and that Mr Middleton was becoming impatient and worried. He was also concerned about the amount of blood and stated his father was frail and concussed. The call was allocated a category 3 response time. This assessment was not performed correctly, and the call should have been changed to a category 2 which would have resulted in an ambulance would have arrived sooner.

At 22:04 a call was made by Mr Middleton’s son to Yorkshire Ambulance Service requesting an update on the arrival of an ambulance and stating his father’s condition had not changed. A resource was allocated at 22:33 and arrived on scene at 22:47, 6 hours and 6 minutes after the initial call. Mr Middleton was taken to the Northern General Hospital in Sheffield where he was diagnosed with a traumatic acute subdural haemorrhage which was not fit for medical intervention. He died in hospital on 10 Feb 2022 as a result of this injury. The medical cause of death found was: 1a. Traumatic acute subdural haemorrhage
2. Atrial fibrillation, tricuspid valve replacement (anticoagulated), Type II diabetes mellitus, ischaemic heart disease and chronic obstructive pulmonary disease The narrative conclusion given was as follows: Roy Middleton fell at his home address on 9 February 2022. Emergency medical assistance was requested but did not arrive until six hours and six minutes after the request was made due to service demands and a missed opportunity to re-categorise the call. Mr Middleton was admitted to the Northern General Hospital where he was diagnosed with a traumatic acute subdural haemorrhage. He died in hospital on 10 February 2022 as a result of this injury. Had he presented at hospital sooner it is possible he could have been treated but it cannot be said whether he would have survived.