UK Inquiry Tracker

Raymond Davidson

PFD Report Historic (No Identified Response) Ref: 2018-0059

Date of Report 27 February 2018

Coroner Derek Winter

Coroner Area Sunderland

Response Deadline est. 3 August 2018

Community health care and emergency services related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.

View full coroner's concerns

[heard evidence that: the recruitment/retention of staff had improved; and welfare calls triggered earlier clinician involvement than previously; although there were several other initiatives under way, operational shortages were ongoing: Raymond s death highlighted resource issues. There was only so much NEAS could do when simply did not have enough ambulances to send. At times demand was greater than the resources NEAS had available. The effect of urgent cases being interposed put back those cases appearing to be less urgent: In this case: 10 hours 51 minutes elapsed from the original 111 call; 8 hours and 29 minutes after the urgent categorisation; and hour 3 minutes after the case was prioritised as a G2 response This is the third such report about the same issue that I have written in recent months as consider that there is a risk of future deaths. An urgent review of resources and their application is needed Finally from the evidence, there was frequent telephone contact made, but this was not with the patient directly, which may have impacted on the less than robust initial clinical review of Raymond s condition_

Sent To

North East Ambulance Service NHS Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 3 Aug 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 10'h June 2017 Mr Raymond Henry Davidson (Raymond) 69 years, died at his home address. The Inquest; aS part of my Investigation, concluded on 27h February 2018, when I recorded a conclusion of Natural Causes Contributed by Neglect_ The Cause of Death following Post-Mortem Examination was: Ia Large Bowel Voluvlus

Circumstances of the Death

On the 9h June 2017 at 15:19, NEAS received a call into 111 gentleman to highlight concerns for his brother_ At 15.39,the 111 clinician triaged to a GP contact within 2 hours_ On reviewing this call, it was found that this decision was not as robust as it ought to have been. At 17:45 an Urgent booking was received by ambulance control to arrange an Urgent ambulance within 2 hours to transport Raymond into Queen Elizabeth Hospital. No ambulance attended. At 20.11 the first welfare call was completed with no worsening symptoms described This was followed with further welfare calls at 21.54,23.04 and 00.05 with no worsening symptoms described. At 01:05 the Call handler called a clinician to highlight the fifth welfare call was about to be carried out, and advice to upgrade the call was given_ At 01:07 the case was therefore upgraded and prioritised as a G2 emergency response (within 30 minutes). No Ambulance attended_ Raymond s brother_rang 999 at 02.02 as Raymond had stopped breathing Civic Centre Burdon Road,Sunderland, SR2 7DN Tel 0191 5617843 Fax 0191 5537803 WWW.sunderlandcoroner.co.uk City aged from

The case was upgraded to a R l emergency response for within 8 minutes and CPR instructions given_ The Rapid Response arrived on scene at 02:10, but Raymond had sadly passed away before the arrival of the crew_