Ambulance chiefs have apologised to the family of a pensioner who died at his home following a wait of more than eight hours for paramedics to arrive.
Sunderland coroner Derek Winter has said he is to write to health secretary Jeremy Hunt after finding that Raymond Henry Davidson died of natural causes “contributed to by neglect”.
Retired Royal Mail driver Raymond Henry Davidson, 69, took ill at his house in Washington on June 9 last year, suffering from volvulus, when a loop of intestine twists around itself, causing bowel obstruction.
An inquest, held at Sunderland Civic Centre, heard his brother Peter called the NHS 111 service shortly after 3.15pm and after other calls back between clinicians to him, at 5.39pm an urgent call was made to dispatch an ambulance to get to Raymond’s house in Barmston Way and take him to the Queen Elizabeth Hospital, in Gateshead, for treatment, which should have got to him by 7.39pm.
But due to high demand upon the services of the North East Ambulance Service (NEAS) on the day however, no ambulance arrived by that time.
With Raymond’s condition worsening, Peter called 999 and at 1.07am the following morning the call was upgraded so that an ambulance should have arrived by 1.37am.
Again, no ambulance appeared and Peter called again at 2.02am saying that Raymond had stopped breathing.
A rapid response vehicle arrived at 2.10am but by then it was too late and Raymond was pronounced dead just before 2.30am.
Concluding the case, Mr Winter said that Raymond died of natural causes with a rider of neglect.
He said the initial disposal of Raymond’s condition was “not as robust as it could have been” and that he would be making a regulation 28 notice as he believed action should be taken to prevent further deaths.
“I do find that the failure in this case was a gross failure,” he said.
“Not only was their one occasion when the opportunity to get an ambulance to Raymond was missed, initially by 7.45pm, but that further opportunity was not made until 1.37am and even then, that was not offered until his brother rang 999.
“The overall time frame to get Raymond to hospital was almost 12 hours.
“The conclusion that I am going to record is one of natural causes, contributed to by neglect.”
He added: “The issue in this inquest is essentially a matter of resource.
“There is only so much one ambulance service can do and when they do simply not have an ambulance to send, there are going to be problems.”
WE MUST LEARN FROM THISS, SAYS AMBULANCE CHIEF
Douglas McDougall, strategic head of operations at NEAS, told the inquest there had been high demand on the organisation on the day Mr Davidson became unwell.
But he admitted: “It’s not acceptable.
“We failed to respond in a timely manner to Mr Davidson.
“We are the least funded ambulance service in England and Wales and our staff work incredibly hard despite the challenges we face.”
Mr McDougall also said that the service had recently been given funding to recruit 42 more paramedics and 42 support workers.
Dr Catherine Hobday, who carried out a post-mortem on Raymond, who had Parkinson’s disease, told the hearing that the volvulus from which he died of could have been treated in hospital with an endoscopy.
She added: “It is not really a treatable condition outside of hospital,” said Dr Hobday.
“It’s not something perhaps a first aider would have been equipped to deal with.”
Following the inquest, chief operating officer at NEAS Paul Liversidge said: “We strive to deliver the best care and safety to patients that we can with the resources that we have available.
“We regret that Mr Davidson did not receive the care that he deserved and we apologise wholeheartedly to his family for their distress and loss.
“As the provider of such a valuable NHS service in the North East, we will continue to work closely with commissioners and partners to improve our service and identify opportunities to learn from incidents like this.
“We will take on board and act upon all feedback from the coroner.”
FAMILY HOPE RESOURCES IMPROVE
After the hearing, Raymond’s family said they hoped that the situation with NEAS resources would improve.
Peter, 64, said: “It’s very encouraging that this has come out.
“The ambulance service have been very honest about their problems.
“However, apologies are all well and good, but that does not change the circumstances.”
Raymond’s older brother John, 71, said: “We are happy with the conclusion but I’m quite concerned with the 111 service as I think it is impossible to correctly diagnose someone over the phone.
“That is my big issue with what happened to my brother and I’m glad I have had the opportunity go public about it.”