Edna Wiggett
PFD Report
All Responded
Ref: 2026-0163
All 1 response received
· Deadline: 13 May 2026
Coroner's Concerns (AI summary)
Ambulance dispatch was delayed due to a failure to re-triage and re-classify a patient's case after receiving updated information about increased pain.
View full coroner's concerns
(1) the failure to re-triage Mrs. Wiggett’s case and consider a re-classification following receipt of a second call providing relevant information (an increase in pain) leading to delays in the dispatch of an ambulance.
Responses
Action Taken
• An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be discussed at the Learning Group where potential themes are discussed. (AI summary)
• An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be discussed at the Learning Group where potential themes are discussed. (AI summary)
View full response
Dear HM Coroner Robin Weyell
I am writing further to the inquest into the death of Edna May Wiggett, which concluded on 13 March 2026. I understand you did not call any live witnesses from EEAST to attend the inquest in respect of the handling of the 999 calls on 19 and 20 September 2025, however you did request an investigation report to address the management of the calls shortly before the inquest.
This investigation report identified that, although the first 999 call received for Mrs Wiggett was triaged correctly and appropriately managed, there was a missed opportunity in respect of the second 999 call to re-triage the call based on her changing presentation. The report further confirms that EEAST was under significant operational pressure that night, arising from high call demand and delays in ambulance handovers at acute hospitals across the region.
Following the inquest you issued a Regulation 28 (Preventing Future Death) report to EEAST outlining your concern that
1) the failure to re-triage Mrs Wiggett’s case and consider a re- classification following receipt of a second call providing relevant East of England Ambulance Service NHS Trust
EEAST Whiting Way Melbourn SG8 6NA
Chief Executive: Neill Moloney Chair: Mrunal Sisodia OBE
information (an increase in pain) led to delays in the dispatch of an ambulance.
A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.
Please do not hesitate to contact me should you require any further information.
I am writing further to the inquest into the death of Edna May Wiggett, which concluded on 13 March 2026. I understand you did not call any live witnesses from EEAST to attend the inquest in respect of the handling of the 999 calls on 19 and 20 September 2025, however you did request an investigation report to address the management of the calls shortly before the inquest.
This investigation report identified that, although the first 999 call received for Mrs Wiggett was triaged correctly and appropriately managed, there was a missed opportunity in respect of the second 999 call to re-triage the call based on her changing presentation. The report further confirms that EEAST was under significant operational pressure that night, arising from high call demand and delays in ambulance handovers at acute hospitals across the region.
Following the inquest you issued a Regulation 28 (Preventing Future Death) report to EEAST outlining your concern that
1) the failure to re-triage Mrs Wiggett’s case and consider a re- classification following receipt of a second call providing relevant East of England Ambulance Service NHS Trust
EEAST Whiting Way Melbourn SG8 6NA
Chief Executive: Neill Moloney Chair: Mrunal Sisodia OBE
information (an increase in pain) led to delays in the dispatch of an ambulance.
A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.
Please do not hesitate to contact me should you require any further information.
Sent To
- East of England Ambulance NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
13 May 2026
All responses received
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 03 October 2025 I commenced an investigation into the death of Edna May WIGGETT aged 85. The investigation concluded at the end of the inquest on 13 March 2026. The medical cause of death was: 1a) Heart Failure 1b) Osteoporotic Fractured Neck of Femur (Operated 27.9.25); New Atrial Fibrillation 1c) Fall with Long Lie 1d)
2) Hypertension; Chronic Kidney Disease; Frailty The conclusion of the inquest was: Edna May Wiggett never recovered from essential surgery for a fractured hip and other injuries following an earlier fall at her home. The long wait she had lying on the floor waiting for an ambulance before her admission more than minimally contributed to her death.
2) Hypertension; Chronic Kidney Disease; Frailty The conclusion of the inquest was: Edna May Wiggett never recovered from essential surgery for a fractured hip and other injuries following an earlier fall at her home. The long wait she had lying on the floor waiting for an ambulance before her admission more than minimally contributed to her death.
Circumstances of the Death
On Twenty-Ninth September 2025 at Norfolk and Norwich University Hospital, Colney Edna May Wiggett died from heart failure following surgery after she had had a fall at home. The long wait she had lying on the floor waiting for an ambulance more than minimally contributed to her death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.