On 11th July 2018 an investigation was commenced into the death of Gladys Esme FURNIVAL (known as Esme FURNIVAL) dob 5th September 1926. The investigation concluded at the end of the inquest on 10lh 2019. The conclusion of the inquest was accidental death. medical cause of death was Ia multi organ failure, 1b traumatic ischaemic injury to abdomen and Ic fall.

At approximately 12.30hrs on Sunday 8" July 2018 Esme Furnival had an unwitnessed fall at her home address a sheltered accommodation in Holmes Chapel, Cheshire , whereby her dressing gown waist cord was caught in the fridge thereby suspending her body with her legs on the floor and her upper body off the floor. Careline monitoring services received a call from Esme at 12.40hrs during which they separately called 999 services at 12.44hrs That call was given a category 3 response with an expected response time of 90"h percentile of 120 minutes. North West Ambulance Service called Careline back at 14.43hrs to inform them that there was significant delay to responding that due to the volume of calls received. The response was not upgraded to a category 2 but Esme was placed as the top priority within the waiting category 3 responses The ambulance service arrived at her flat at 17.23hrs and she was transported to Leighton hospital where she sadly died on 9ih July 2018 Careline are a remote service and they attempted to contact the manager of the sheltered home and the listed next of kin without success

In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action.