“The amount of time taken for the ambulance to arrive which was markedly outside the…”

The coroner’s concerns

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— (1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust's guidelines. (2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm. (3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis. The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk. In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant. It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which | feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are systemic failures within your organisation which should be addressed. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you and the East of England Ambulance service NHS Trust have the power to take such action.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0183

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0