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Found 322 results
  1. News Article
    National NHS officials have called for ambulance response times for stroke cases to be “urgently reviewed”. A report on stroke services by Getting it Right First Time – an NHS England national programme – recommends modelling the impact of a change to the categorisation by ambulance services of suspected strokes. The GIRFT report notes that the time between symptom onset and arrival at hospital has increased by 41 minutes over the last seven years, yet faster access to emergency stroke care gives a better chance of survival and reduces the impact on quality of life for survivors. Strokes are currently treated as “category two” incidents, meaning they should get a response within 18 minutes. However, patients are currently experiencing much longer waits, as average response times were more than three times this in March. Since the introduction of the current system of categorisation in 2017-18, the 18 minute target for category two calls was only ever hit for a few months, at the height of the covid pandemic, when call-outs were abnormally low. However, when asked about the issue, Janette Turner, the academic who led research on the last official review of ambulance response times, warned that moving all suspected strokes to category one could lead to longer responses for the most serious calls. Read full story (paywalled) Source: HSJ, 4 May 2022
  2. News Article
    More than 38,000 patients were put at risk of harm during March – more than 4,000 of them seriously – while they waited in an ambulance outside hospital, according to estimates shared with HSJ. The number of hour-plus delays to handing over patients from ambulances to emergency departments in March was the highest ever recorded, following steep increases since last summer. Figures collected by the Association of Ambulance Chief Executives (AACE), and shared with HSJ, reveal that one trust recorded a delay of 23 hours during March. Based on its detailed information about the length of handover delays, AACE has produced an estimate of the likely number of patients harmed while waiting to he handed over, using a model initially developed in research published last year. This found 85 per cent of those who waited more than an hour could have suffered potential harm. The AACE report said that patients who waited the longest were at greatest risk of some level of harm and the risk of severe harm tripled for those waiting for more than four hours compared with waiting for 60 to 90 minutes. AACE managing director Martin Flaherty told HSJ: “We expect the situation to be no better when we collate our figures for April. “The most significant problem remains hospital handover delays which continue to increase exponentially, with tens of thousands of ambulance hours being lost due to hospital handover delays, causing enormous knock-on effects out in the community, where delays in people receiving the ambulance resource they need are the obvious result. “However, the human cost, in terms of direct harm that is being caused to patients through these combined delays at hospitals and in the community, as well as to the health and wellbeing of our ambulance crews, is substantial." Read full story (paywalled) Source: HSJ, 29 April 2022
  3. News Article
    An NHS boss who had a stroke was taken to A&E by her husband rather than calling for an ambulance because of concerns over long waits. In a series of tweets, Gloucestershire Hospitals NHS Trust chief executive Deborah Lee praised his swift actions. She said he had "bundled her into his car", last week, after she had showed the signs of a stroke because he had heard her "lamenting ambulance delays". She is recovering but says it may have been different if they had called 999. Waits for an ambulance in England are the longest since new targets were introduced, in 2017. And Ms Lee's regional service - the South West - has the longest waits in the country, with category-two calls, which include strokes, taking nearly two hours, on average, to reach patients in March. The target is 18 minutes. In the tweets, Ms Lee said: "Naturally, I am eternally grateful to my husband for his swift actions… but I can't get one thing out of my head. "What if my husband hadn't been there and my daughter had called for an ambulance and I'd been put in the cat[egory]-two stack?" She went on to say it was not the fault of the ambulance service and the whole system was "working unrelentingly to this but to no great avail". Ms Lee said hospitals were struggling to discharge patients, because of a lack of social care, and so delays were building up in the rest of the system. Read full story Source: BBC News, 28 April 2022
  4. Content Article
    Recently the Financial Times health and data reports produced an incisive piece showing the world what is all too readily apparent to people in the NHS: bed capacity has been stretched to breaking point. The report said this “calls into question [the NHS’s] ability to meet a commitment to increase non-urgent hospital treatment by 30 per cent above pre-pandemic levels over the next three years”. It also demonstrates the dangerous congestion that is causing ambulances to stack up outside emergency departments and medically fit patients to languish in vital beds past their due time for discharge. This congestion is causing dangerous delays, leading to a rising number of serious incidents in ambulances queuing to get to the front door of the ED. There is doubtless much that can be done inside hospitals to improve efficiency, alleviate bottlenecks and improve patient flow.
  5. News Article
    A woman has described how she spent more than six hours of her 100th birthday waiting in agony for an ambulance after slipping and fracturing her pelvis while getting ready for a family lunch. Irene Silsby was due to be picked up by her niece, Lynne Taylor, for a celebration to mark her centenary on 9 April. But she fell in the windowless bathroom of her care home in Greetham, Rutland, and staff called an ambulance at 9am after she managed to summon help. “All I remember is I was in terrible pain,” said Silsby from her hospital bed on Saturday. When asked of the ambulance delay, she said: “It’s disgusting. I don’t know how I stood it so long, the pain was so severe.” Taylor expected to meet the ambulance as she arrived 45 minutes later. But when she reached the care home, the manager said it would be a 10-hour wait, she said. What was to be her aunt’s first trip outside the care home in more than five months turned into her lying on a cold floor surrounded by pillows and blankets to keep her warm and quell some of the discomfort. Taylor, 60, recalled her aunt saying: “They’re not coming to me because they know I’m 100 and I’m not really worth it any more.” Taylor said she had never felt so scared, frustrated and worried. After calling 999 and expressing her outrage, she was told that life-threatening conditions were being prioritised. “I thought she was going to die,” she said. “I didn’t think that any frail, tiny, 100-year-old body could put up with that level of pain on the floor.” Read full story Source: The Guardian, 20 April 2022
  6. News Article
    Ambulance trusts are seeing rising numbers of serious incidents resulting from delays in reaching patients, research by HSJ has uncovered. Serious incidents are defined by the NHS as a patient safety failure “where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified.” East Midlands Ambulance Service Trust saw 71 serious incidents in 2021-22 compared with 38 in the financial year before. The trust’s board papers attribute the increase in SIs related to delayed responses since June 2021 to “sustained pressure on the service” and the resulting growing handover times at accident and emergency departments. Of 14 SIs reported in February and the first half of March 2022, seven were due to “prolonged waits for an ambulance response”. West Midlands University Ambulance Service Foundation Trust has also seen an increase in SIs. Its board papers report that half of the SIs are due to “delays in reaching patients resulting in harm, serious harm, and deaths”. It has given the issue of “hospitals, breaches, delays and turnaround times” the maximum rating of 25 on its risk register. Long delays – especially for category two patients, where average performance last month was above an hour – are causing increasing concern. Stroke Association chief executive Juliet Bouverie said the organisation was hearing “shocking accounts from stroke survivors who have waited hours for an ambulance… We are extremely worried that stroke survivors’ lives and recoveries are being put at extreme risk.” Read full story (paywalled) Source: HSJ, 20 April 2022
  7. News Article
    Volunteers will transport patients who need extra assistance to hospital to increase ambulance availability for higher-risk patients. The pilot scheme, using ambulance cars, is due to start in London in May. London Ambulance Service said the trained volunteers would be sent to lower category 999 calls where the patient needed help to get to hospital. The service's board meeting was told the scheme would reduce waiting times and increase ambulance availability. Currently, taxis are used to transport "low acuity patients" to hospital, the meeting heard. But there were some patients who required "the assistance of one person to walk or mobilise", which taxis could not provide. "This results in the dispatch of an emergency ambulance, reducing ambulance availability for higher priority incidents and longer waiting times for patients," the meeting heard. As part of the pilot scheme, a volunteer car would be dispatched to these patients. A spokesperson for the service said: "This project builds on our well-established network of volunteers who respond to emergencies to help ensure our ambulances can reach the patients that need us the most. "These fully trained volunteers, who already respond to 999 calls in their communities, will help patients who have been assessed not to need of an ambulance but who may need more support than a taxi can provide." Read full story Source: BBC News, 18 April 2022
  8. Content Article
    Sean Mansell had a medical history of alcohol dependence syndrome. On the 5 July 2021, the West Midlands Ambulance Service received a 999 call at 19.23 hours from a neighbour of who reported that Shaun couldn't walk. The call was allocated a category 3 disposition which had a target response time frame of 120 minutes. An ambulance arrived on scene at 03.38 on the 6 July which was 8 hours and 15 minutes later and not within the response time frame. This was due to the fact that demand outstripped available resources. A welfare call was undertaken at 21.28 hours by a paramedic who had been asked to go into the control room to assist with welfare calls due to the high volume of 999 calls outstanding. The paramedic had not received prior training on how to complete these calls. The welfare call was conducted with the neighbour. No contact was made directly with Shaun during the 8 hour delay which led to a missed opportunity to identify a change in his condition. When the ambulance arrived, Shaun had passed away on the sofa in his front room. There was evidence of blood loss on the floor next to him and around his mouth. The police did not find any suspicious circumstances. A post mortem examination found the cause of death to be acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism. The medical evidence was not able to determine if the delay in the arrival of the ambulance contributed to the death because there was no certainty of timeline about the bleeding. 
  9. News Article
    More than four hours after an ambulance was called, Richard Carpenter, 71, who had had a suspected heart attack, began to despair. “Where are they?” he asked his wife, Jeanette. “I’m going to die.” She tried to reassure her husband that the crew must surely be close. Perhaps they were struggling to find their rural Wiltshire home in the dark. “But I could see I was losing him,” she said. She gave her husband CPR and urged him: “Don’t leave me.” But by the time the paramedics arrived another hour or so later, it was too late. Jeanette Carpenter, 70, a stoical and reasonable person, accepts it might have been impossible to save her husband. “But I think he would have had more of a chance if they had got here sooner,” she said. It is the sort of sad story that is becoming all too common. Across England, but in particular in the south-west, ambulances are too often not getting to patients in a timely manner. Before Covid, said one ambulance worker – who asked not to be named – he would do between six and 10 jobs in a shift. Now if the first person he is called to needs to go to hospital, he expects this will be his one job for the whole shift. “At some hospitals we are waiting outside hospitals for 10, 11 or 12 hours,” he said. “There’s nothing more demoralising than hearing a general broadcast going out for a cardiac arrest or road accident and there’s no resources to send. It’s terrible to think someone’s loved one needs help and we can’t do anything because we’re stuck at a hospital.” Read full story Source: The Guardian, 10 April 2022
  10. News Article
    An ambulance service has raised concerns over the record number of ‘hours lost’ to handover delays at an acute hospital on its patch, which it says is happening despite the number of arrivals being at its lowest level in seven years. West Midlands Ambulance Service University Foundation Trust has said the situation at Royal Stoke Hospital presents a “significant risk to patient safety”, but “we don’t currently see actions being taken that are reducing this risk”. It comes amid rising frustrations from ambulance chiefs around the country at a perceived lack of support from acute hospitals around handover delays. Ambulance response times for some of the most serious 999 calls have ballooned in recent months, in part due to lengthy handover delays at emergency departments. In a letter sent to a member of the public on 31 March, Mark Docherty, director of nursing at WMAS, said: “WMAS [is] experiencing difficulties as a direct result of delays in patient handovers at acute hospitals. We have been highlighting our concerns for over six years as the situation has become progressively worse every year." Read full story (paywalled) Source: HSJ, 10 April 2022
  11. News Article
    An 86-year-old man died after lying in the road waiting more than four hours for an ambulance, his family have said. George Ian Stevenson was hit by a car near his home in Johnstown, Wrexham county, last Wednesday. His family said the first 999 call was made at 19:31 GMT, and the ambulance did not arrive until 23:37 GMT. The Welsh Ambulance Service is looking into the incident, but said that at the time of the call, all its vehicles were already committed to other patients. Two off-duty paramedics stopped to help, but were reluctant to move him in case they caused further injury. Mr Stevenson's granddaughter, Ellie Williams said on the night of the accident it was raining, freezing and foggy. She said: "Left there for four hours, begging for help, waiting for help. And that makes us so sad. "A hard-working man who has paid his taxes all his life and paid into the system has been let down when he's needed them the most, and I just can't quite comprehend what has happened to him." Read full story Source: BBC News, 8 March 2022
  12. News Article
    Ambulance staff are experiencing “horrific” abuse from the public as attacks on workers increased by 23% in the wake of the pandemic. Assaults against female ambulance staff have risen by 48% in the last five years, according to a new report from the Association of Ambulance Chief Executives (AACE). In response to rising attacks, the NHS has launched a #workwithoutfear campaign to prevent abuse of ambulance staff. Last year there were 11,749 attacks against ambulance staff, equating to 32 workers being abused or attacked every day. AACE said incidents included kicking, slapping, headbutting and verbal abuse, and ranged from common assault to serious attacks involving knives and weapons. Daren Mochrie, chair of AACE and chief executive of North West Ambulance Service said ambulance staff “face the possibility of violence, assault and aggression” on every shift. “When they occur, these attacks have a significant and lasting impact on the team member, affecting every aspect of their life." Read full story Source: The Independent, 28 February 2022
  13. News Article
    Callers to NHS 111 services are twice as likely to be judged as needing an ambulance in some regions as others – and up to eight times more likely to abandon their calls. An HSJ investigation has revealed striking differences in performance between 111 providers. The new integrated urgent care data set, published by NHS England, shows the differences in performance across the country. HSJ analysed data from April to December last year – the first year this data set has been produced. For example, 15.7% of answered calls to North East Ambulance Service Foundation Trust resulted in an “ambulance disposition” while just 7.7% of calls to London Ambulance Service Trust did so. A total of 14.2% of callers to the privately owned Practice Plus Group were judged to require an ambulance. 41.9% of calls were abandoned before being answered by NEAS and 30.6% of those made to the West Midlands Ambulance Service University FT ended the same way. In contrast just 5.2%of callers from Lincolnshire to services provided by Derbyshire Health United abandoned their calls. The “standard” for abandoned calls is just 3%, but the average performance across England was 24.1%. In a statement, the Practice Plus Group said its staff were trained to a high standard on NHS Pathways and it was confident its staff were making appropriate and safe decisions. Over 70 per cent of decisions to instigate a category 3 or 4 ambulance callout were validated in January. As a result ambulances were dispatched in just 20 per cent of those cases, with other patients being directed to alternative pathways. “We are always looking to enhance the service which is why we are running developmental training for our call handlers in more effective probing to reduce the category 2 ambulance disposition numbers and have introduced GoodSam video technology as part of an NHSE pilot which will support clinicians with eyes on with a patient,” the company added. Read full story (paywalled) Source: HSJ, 18 February 2022
  14. News Article
    NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief operating officer, nursing director and medical director, but also by the CQC’s chief inspector of hospitals Ted Baker. It said there was a “strong correlation” between handover delays at hospitals — which take place where A&Es are unable to receive patients from ambulances — and long delays for category two ambulances. This is because ambulances have to wait for long periods outside the hospitals. The letter said: ”It is vital that we have a whole-system approach to considering risks across the urgent and emergency care pathway to provide the best outcomes for our patients. This may mean consideration of actions to be taken downstream to help improve flow and reduce pressures on emergency departments.” Read full story (paywalled) Source: HSJ, 17 February 2022
  15. News Article
    Two acute trusts account for almost two-thirds of emergency department ‘diverts’ reported over the last two months. Between the start of December and the start of February, Worcestershire Acute Hospitals Trust and University Hospitals Sussex Foundation Trust implemented 122 temporary “diverts” between them – representing around 60% of the national total. The measure is taken when a particular site, such as Worcestershire Royal or Royal Sussex County Hospital, comes under significant pressure and ambulances are temporarily directed to an alternative hospital, usually within the same trust. NHS England guidance says diverts of emergency patients due to lack of physical or staff capacity to deal with attendances or admissions “should be an action of last resort” and that this “should only need to happen in exceptional circumstances, where internal measures have not succeeded in tackling the underlying problem”. Helen Hughes, chief executive of Patient Safety Learning, said: “For ambulance services, the impact of A&E diverts is two-fold. It both increases the length of journeys that crews have to make once a divert is implemented, and increases the travel time required to get back to subsequent emergency calls." “This has the potential to increase waiting times for patients, increasing the risk of avoidable harm, particularly for those who are seriously ill, frail or elderly.” Read full story (paywalled) Source: HSJ, 15 February 2022
  16. Content Article
    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.
  17. News Article
    Over half of paramedics are suffering from burnout caused by “overwhelming” workloads, record numbers of 999 calls and the public misusing the ambulance service, a study has found. Frontline crew members also blame lack of meal breaks, delays in reaching seriously ill patients and their shift often not ending when it should for their high levels of stress and anxiety. The working lives of ambulance staff are so difficult that nine out of 10 display symptoms of “depersonalisation”, characterised by “cynicism, detachment and reduced levels of empathy” when dealing with patients who need urgent medical treatment. The widespread poor mental welfare of paramedics is a problem for the NHS because it is leading to some quitting, thus exacerbating its shortage of ambulance personnel, the authors said. The findings, published in the Journal of Paramedic Practice, have prompted concern that the demands on crews, alongside the injury, violence and death they encounter, are storing up serious mental health problems for them, including post-traumatic stress disorder. “Ambulance staff are passionate about their role. However, burnout is a significant and very real issue that decreases staff efficacy and reduces quality of patient care,” the study said. It was undertaken by Rachel Beldon, who works for the Yorkshire ambulance service, and Joanne Garside, a professor and school strategic director of Huddersfield university’s health and wellbeing academy. “Participants wanted better resources and staffing levels. The current workload appeared to be overwhelming and negatively affected their mental health and work-life balance.” Read full story Source: The Guardian, 6 February 2022
  18. Content Article
    Staff retention is a significant issue for ambulance services across the globe. Exploratory research, although minimal, indicates that stress and burnout, in particular, influence attrition within the paramedic profession. These need to be understood if their impact on retention is to be addressed.
  19. Content Article
    This study in the Journal of Patient Safety assessed the occurrence of incidents in inter-hospital transport for critically ill patients, their potential consequences, and whether they are actually reported. Two different services in Norway were asked to self-report incidents after every inter-hospital transport of critically ill patients. The study found that only 1% of incidents were actually reported in the hospital’s electronic incident reporting system. It also highlighted that experts who examined the incidents were inconsistent in which incidents should have been reported and to what degree different interventions could have prevented them. The study results show the existing quality and safety challenges relating to inter-hospital transport of critically ill patients.
  20. News Article
    An ambulance trust has apologised after a man having a heart attack said he was advised to get a lift to hospital or face a long wait. Graham Reagan said he was on the verge of collapsing when he finally got to York hospital after a lift from his son. Mr Reagan said he was concerned about the impact on patients with potentially life-threatening conditions. Speaking to BBC Yorkshire and Lincolnshire's Politics North programme, Mr Reagan described his experience as "scary". "I'd had indigestion, or so I thought, for a couple of days, and then on 17 December I went to bed early feeling rough," he said. In the early hours, Mr Reagan said the pains in his chest grew worse and he asked his wife to call for an ambulance. "I couldn't take it any more," he said. Mr Reagan, from Malton in North Yorkshire, said his wife was asked "can you get to hospital" as the nearest ambulance was about 20 to 30 miles away. "My wife doesn't drive, but fortunately my son was with us and he drove me to York hospital." On arrival Mr Reagan said they found the entrance to A&E had also been re-routed. "So, we then had to walk out of the hospital grounds and back in - by which time I'm collapsing," he added. He said staff at the hospital were "absolutely brilliant" and arranged for him to be transferred to Hull for treatment after a heart attack was confirmed. However, he said he was faced with a further 35-minute delay while he waited for an ambulance to take him. Mr Reagan said he wanted to share his experience to raise awareness. Read full story Source: BBC News, 16 January 2022
  21. Content Article
    "Patients wait up to 12 hours. Some die waiting. How long must we wait for this dire situation to improve?" The NHS is overwhelmed. Although Covid has shone a bright light on this, it alone did not create these problems. There are multiple reasons for failure writes the'Secret Paramedic' in this Guardian article.
  22. News Article
    A health minister has asked NHS England to look into a stricken ambulance trust that is asking patients to get a lift to A&E. The North East Ambulance Service (NEAS) said staff should “consider asking the patient to be transported by friends or family.” See previous news story. NEAS medical director Dr Mathew Beattie said the service had “no option than to try to work differently” amid Covid staff shortages. However, Health Minister Gillian Keegan said she would ask NHS England to look into the situation. She told Sky News: "That is not what we have put in place at all. We have more ambulance crews in operation than we have ever had." “We also gave £55 million extra just for this period to cover staff and make sure we had increases in staff and staffing levels. "I've actually asked NHS England to look at that particular case because that doesn't sound to me like that's an acceptable approach. “People should be able to get an ambulance if they have a heart attack and that's why we've put that extra funding in place, and why we've been building up our ambulance service over the last couple of years." Read full story Source: Mirror, 5 January 2022
  23. News Article
    Ambulance trusts have begun asking patients with heart attacks and strokes to get a lift to hospital with family or friends instead of waiting for an ambulance, because of high covid absences and ‘unprecedented’ surges in demand, HSJ has learned. An internal note at North East Ambulance Service Foundation Trust said that where there was likely to be a risk from the delay in an ambulance reaching a patient, call handlers should “consider asking the patient to be transported by friends or family”. This applies to calls including category two, which covers suspected strokes and heart attacks, according to the note seen by HSJ. It said call handlers should “consider all forms of alternative transport” for patients. The note from medical director Mathew Beattie gives the example of a person with chest pain who would normally get a category 2 response – with a target of reaching them within 18 minutes – but where the ambulance response time would be two hours. In the message to staff, Dr Mathew Beattie said: “To manage [current] unprecedented demand, we have no other option than to try and work differently which I am aware will not sit comfortably but is absolutely essential if we are to sustain a service to those who need it most." “We need to weigh up the risk of delays for ambulances against alternative disposition or transport options. Where such risks are considered, I want you to be aware that the trust will fully support you in your decision-making under these circumstances.” Read full story (paywalled) Source: HSJ, 4 January 2022
  24. News Article
    Nearly a quarter of patients brought to hospital in an ambulance are facing dangerous delays getting into hospital in England, NHS data shows. Ambulances are meant to hand over patients within 15 minutes of arriving. But in the past week 23% out of nearly 84,000 patients brought in waited over 30 minutes. Staff are warning patients are being put at risk by the delays - and they think the situation is only going to get worse as Covid infections rise. At seven NHS trusts more than half patients were left waiting over half an hour with nearly two thirds delayed at Gloucestershire Hospitals NHS Trust. Association of Ambulance Chief Executives managing director Martin Flaherty said the situation was a major concern. "The extent of potential harm that is being caused to patients when there are lengthy delays remains a significant and growing problem." He said work was going on to tackle the issue, but around a quarter of hospitals were really struggling. Read full story Source: BBC News, 16 December 2021
  25. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to recognition of the acutely ill infant and child, recognising the difficulty in distinguishing between simple viral illnesses and life-threatening bacterial infections in very young patients. This Healthcare Safety Investigation Branch investigation reviewed the case of Mohammad, a baby who had become unwell and was taken to an emergency department by ambulance following a call to NHS 111. He arrived at 8.04pm and was considered to have a mild viral illness, subsequently being transferred to a paediatric observational ward, and discharged at 11.45pm with a diagnosis of likely bronchiolitis. At approximately 3.40am his mother contacted the ward as his condition worsened, which resulted in a 999 call. The ambulance crew did not consider that Mohammad was seriously ill so did not conduct a ‘blue light’ emergency transfer to hospital. Mohammad was admitted to the emergency department at approximately 4.40am and suffered a respiratory and then cardiac arrest at 5:28am, with attempts to resuscitate unsuccessful and stopped at 6:10am. Mohammad died of septicaemia caused by meningococcus (serogroup B) bacteria.
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