“Evidence given at the inquest revealed that there was a delay in Mr”

The coroner’s concerns

– (1) Evidence given at the inquest revealed that there was a delay in Mr. Athanasis being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into. (2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed. (3) In this instance the mechanism to undertake a safety check was not sufficient to reveal the extent of the injuries Mr. Athanasis had sustained, and this meant there was a delay in diagnosing him with his unstable cervical fracture. This delay in conjunction with other issues more than minimally or trivially contributed to his death. (4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner. (5) Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40). There are clear risks of future deaths for patients waiting for an ambulance as well as to patients whose diagnosis and treatment is delayed due to limited intervention being available in the back of an ambulance.

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, 2023-0007

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