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Coroners share concerns as ambulance delays contribute to fatalities

Serious concerns are being raised by coroners about the delays in ambulance response times and emergency care within the NHS.

Coroners are independent members of the judiciary presiding over inquests. The purpose of an inquest is to investigate a death which appears to have an unknown, violent or unnatural cause, with the aim of finding out the identity of the deceased and where, when and how their death came about.

When is a Prevention of Future Deaths report issued?

As part of this process, coroners are required to consider any concerns that have arisen in the inquest that mean that there could be ongoing risks to people’s lives. Where a risk is identified, they have an obligation to issue a Prevention of Future Deaths report, sometimes also known as a Regulation 28 report.  A total of 222 Prevention of Future Deaths reports were published in the first half of this year in England and Wales alone. At least 24 of these raise concerns about the delays in emergency care.

Whilst a concern included in such a report may not have been causative of the death, it's clear that delays in receiving emergency care can have fatal consequences. One example of this was described in the Prevention of Future Deaths report issued following the inquest into the death of Sandra Diane Finches. Miss Finches was a 44-year-old Type 1 diabetic and her glucose levels started to rise dangerously after she took some antibiotics. She called for an ambulance reporting high glucose levels, feeling sleepy and vomiting. Her call was categorised as category 3; however, before an ambulance could be dispatched, a clinical review was required which was not attempted until 10 hours later, as a result of understaffing. The call was unanswered and, instead of choosing to send an ambulance straight away, the case was put back into the workload for an attempt to call again. It was not until the next day, when a decision was made to change the categorisation to category 2, that an ambulance was dispatched and Miss Finch was found dead in her home. As a result of errors and understaffing in the ambulance service, Miss Finch sadly had the option of treatment taken away from her. 

It was also suggested at the inquest that Miss Finch’s call should have been categorised as category 2 from the outset, as opposed to category 3. However, it was found that even with her call being categorised as category 3, had the ambulance service not been overwhelmed and ambulances dispatched within their accepted timeframe for each category, Miss Finch would not have died at home before any assistance arrived. 

Concerns over delays in ambulance services

These concerns are not only shared by coroners, but those actually working within the ambulance service on the front line. According to a  study undertaken by the GMB Union earlier this year, one third of ambulance workers have been involved with cases where a patient’s death was linked to the delay in the ambulance service arriving.

NHS attempts to improve services

The NHS have made attempts to improve the delays within their service, particularly in urgent and emergency care. Their objective for 2023/24 is to reduce category 2 ambulance response times to an average of 30 minutes. Despite this improvement, the response time will still be significantly longer than the equivalent pre-pandemic response time of 21 minutes and 15 seconds recorded in March 2019. Nearly three and a half years following the beginning of the pandemic, people continue to suffer the devastating consequences of the delays of an overstretched NHS service. 

As a Medical Negligence solicitor, I all too often see the real impact that these delays are having on individuals and their families. 

Find out more about Irwin Mitchell's expertise at our dedicated medical negligence section.