Philip Hayes
PFD Report
Historic (No Identified Response)
Ref: 2019-0363
Coroner's Concerns (AI summary)
Significant ambulance dispatch delays and a failure to reassess a deteriorating patient resulted from inconsistent triage by untrained health advisors who inadequately considered reported symptoms of a medical emergency.
View full coroner's concerns
(1) in ambulance dispatch Call categorised C2 received response hour 2 minutes after original call (2) Failure to conduct reassessment f C2 category notwithstanding 5 subsequent calls describing additional symptoms and a deteriorating condition (3) Inconsistency in approach and answers to algorithm question designed to indicate risk of aortic aneurysmlruptureldissection On Delay
Calls triaged by health advisors with limited medical training and no medical qualifications (5) Inconsistency in approach to referral for clinical input (6) Appropriateness of triage by algorithm Insufficient if any Weight given to actual reported symptoms and indicators of a medical emergency
Calls triaged by health advisors with limited medical training and no medical qualifications (5) Inconsistency in approach to referral for clinical input (6) Appropriateness of triage by algorithm Insufficient if any Weight given to actual reported symptoms and indicators of a medical emergency
Sent To
- North East Ambulance Service
Response Status
Linked responses
0 of 1
56-Day Deadline
3 Feb 2020
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24 April 2019 opened an investigation into the death of Philip Richard Hayes aged 60yrs. The investigation concluded at the end of the inquest on 29 October 2019. The conclusion of the Inquest was: Medical cause of death: Aortic dissection Way the
Conclusion: Natural causes
Conclusion: Natural causes
Circumstances of the Death
14 April 2019 in or around 13:13 Philip Hayes suffered an aortic dissection; Initial symptoms were chest and flank pain: At 13.13 a 999 call was made to summon urgent assistance. The call was triaged at 13:16 and categorised C2 response (18 minutes): At 13.23, 13.27, 13.31 , 13.45 and 13.59 further calls reporting new symptoms and a deteriorating condition were made. These subsequent calls did not result in a reassessment of the original categorisation nor did the calls result in the case being referred for clinical input. Ambulance technicians arrived at 14.02 and paramedics at 14:15 (1 hour and 2 minutes after the original call) Philip Hayes was transported to the Northumbria Specialist Emergency Care Hospital, arriving at 15.13. His dissection was diagnosed following CT scan at approximately 23.56 when arrangements for his transfer to Freeman Hospital, Newcastle for specialist vascular care were made. Notwithstanding maximal care and treatment he died there on 18 April 2019
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.