Prevention of future deaths report: David Strachan (27 February 2023)

Summary

David Colin Strachan was aged 76 years when he died on 16 March 2022 at his home address in Uangollen, Denbighshire. At 23.20 hours on 15 March 2022, he experienced a sudden onset of chest pain, vomiting and became clammy with shortness of breath. A number of 999 calls were made to the Welsh Ambulance Service but it was not until 9.10am, some 9 hours and 52 hours from the initial call that an ambulance and paramedics arrived. An ECG by paramedics indicated that Mr Strachan had suffered an ST elevation myocardial infarction. He was conveyed directly to the North Wales Cardiac Centre at Ysbyty Gian Clwyd and following investigations he was transferred to the Coronary Care Unit. On arrival his breathing weakened and he died at 12.27pm on 16 March 2022 in hospital.

The cause of death was recorded as:

• 1a. Acute myocardial infarction
• 1b. Coronary artery atheroma.

Content

Coroner's Matters of Concern:

• The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites.
• The matters of concern are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in border to address handover delays and yet any improvements appear extremely limiting. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues.