Marjorie McMahon
PFD Report
Historic (No Identified Response)
Ref: 2018-0196
Coroner's Concerns (AI summary)
Significant ambulance response delays occurred for a high-priority patient due to high demand and insufficient resources, far exceeding the guideline response time.
View full coroner's concerns
_ The
Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7lh March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not altended t0 for nearly Ya hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance) The guideline response time was confirmed t0 be 8 minutes
Mrs McMahon was correctly categorised as a level 2 priority at 1.30 pm on the 7lh March 2018 when the North West Ambulance Service were first contacted in respect of her deteriorating condition. Despite this, due to high demand on the service and available resources, she was not altended t0 for nearly Ya hours (in respect of the paramedic) and 2 hours (in respect of attendance of the ambulance) The guideline response time was confirmed t0 be 8 minutes
Sent To
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
0 of 2
56-Day Deadline
4 Sep 2018
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 the 26lh March 2018 an inquest was opened into the death of Marjorie McMahon; The evidence was heard at inquest on the 21s June 2018 and my conclusions were given on the same date_ conclusion left was: Natural Causes_ The medical cause of death was: Ia Community acquired pneumonia II Dementia
Circumstances of the Death
On the 3th March 2018 Mrs McMahon was noted to be chesty by a slaff member at Cherry Tree House Her condition did not cause staff concern until the morning of the 7/h March 2018 when attempls were made to contact her GP without success. At 1,30 pm on the 7lh March 2018 an ambulance was called after staff contacted "111" for advice regarding Mrs McMahon's deteriorating condition. Due to heavy demand on the service paramedic was unable to attend until 2.58 pm. The paramedic provided oxygen and fluid treatment to Mrs McMahon and an ambulance subsequently arrived at 3.30 pm to convey her to A&E at Stepping Hill Hospital. On arrival at hospital she was assessed and commenced on intravenous antibiotics. Despite treatment; her condition continued to decline and she passed away on the 8/3/2018
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have (he power t0 take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.