On the 5th September 2016 commenced an investigation into the death of Susan Ann Smalley. investigation concluded at the end of the inquest on the 8th November 2017. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A massive fronto-temporal parietal acute subdural haemorrhage with frontal contusions occipital skull fracture

On the 8th August 2016 at approximately 14.30 hours Susan Ann Smalley, "Susan" a 67 year old lady suffered a witnessed fall at home_ She fell backwards from standing height onto hard ground. Her family rang emergency services at 14.46 hours_ made three further calls_ The rapid responder arrived on scene at 15.41 hours, nearly an hour after the initial call. At this time Susan was fully conscious, had a laceration to the back of her head and was vomiting: The paramedic requested emergency back up. The ambulance arrived at 16.52 hours; just over two hours after the initial call, delayed arrival of the ambulance was due to demand for the services higher than the resources available. No earlier opportunity to respond to the call has subsequently been identified. Susan was conveyed to the nearest A&E at Cheltenham General ("CG"): During this transfer her right pupil became dilated and her Glasgow Coma Score ("GCS") decreased to
14. Susan arrived at CG at 17.27. Soon thereafter she suffered some facial weakness. She was not formally assessed by the Emergency Department ED") Consultant and was not admitted to CG_ Instead the Consultant decided to transfer Susan to Gloucester Royal Hospital ("GRH") on the basis that it was unclear whether Susan had suffered a stroke or a head injury. If Susan had been formally assessed at this time she would have undergone a CT examination which would have identified the significant head injury she had suffered, Instead the injury remained undiagnosed and Susan was transferred to GRH: Susan arrived at GRH at 17.50 hours_ Her GCS had significantly decreased at this time Susan experienced a tonic clonic seizure. The ED Consultant administered phenytoin, vitamin

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