Prevention of Future Deaths report – Barbara Young (28 January 2022)

Summary

Barbara Young fell downstairs at her home at 11.30am on 15 July 2021, sustaining multiple injuries including fractures of her ribs, spine and skull. Her family immediately called the emergency services and informed the ambulance call handlers that she had fallen downstairs, was not fully conscious and had sustained an apparently severe head injury. An ambulance subsequently arrived at 2.26pm and she was taken to hospital where, due to her reduced mobility, she developed pneumonia. Mrs Young’s conditioned worsened over the coming days and she died on 24 July 2021. 

In her report, the Coroner raises concerns about the ambulance waiting time in this case, and more generally about ambulance response times in cases where elderly patients experience falls.

Content

In this report, the Coroner states that she had been informed that the risk of mortality in the elderly who have suffered significant trauma is high, because they are at greater risk of developing pneumonia. She notes that it is therefore essential that they receive emergency medical care as soon as possible. She highlighted that in this case it took three hours for an ambulance to arrive, and whilst she had no evidence that this delay contributed to Mrs Young's death, she could not confirm that it did not. She stated that future lives could be at risk due to delays in providing a timely emergency response.

She acknowledged the problems faced by the ambulance service over the last two years, problems that have been compounded by the effects of the pandemic and delays in transferring patients into hospital emergency departments. She said she had also been informed that there have been plans in place to improve the responsiveness of the service, however from the evidence provided at this inquest it appears that problems still exist.

She asked to be provided with the following information:

• Confirmation of the action that will be taken to improve the response times of emergency ambulances.
• Confirmation of whether there are any plans to review the categorisation of elderly patients who suffer falls and are more likely to be affected by the risks associated with lengthy periods of immobility.

This report was sent to the Welsh Ambulance Service NHS Trust and the Health Inspectorate Wales.