Coroner flags ambulance concerns after man's death
GoogleA man who died after suffering heart failure could have been saved if requests for a back-up crew had been escalated, a coroner has said.
Jack Shields, 29, died on 28 April 2024 in his Sunderland home, despite "extensive" attempts to resuscitate him.
An inquest concluded the cause of his death was the worsening of a heart condition while "an ambulance allocation was significantly delayed".
However, a prevention of future deaths report published by the coroner last week said a higher priority back-up request by the crew who eventually attended might "have led to rapid stabilisation and transportation to definitive care".
Nerams, which provided the ambulance, said it had carried out an investigation.
Director of Operations Dean Wrightson said he was sorry for Mr. Shields' death and wanted to pass on his condolences to his family.
"We have undertaken a full investigation so that the lessons learned from this tragic incident help to inform our treatment for future patients," he said.
"In this case, the request for back-up assistance was not appropriately categorised."
He added that assistance for Mr Shields arrived within 15 minutes.
Mr Shields's medical history included a number of "extensive heart conditions" and he had had three open-heart surgeries.
At about 23:15 BST on 27 April last year, his mother called 999 after he had a shortness of breath.
The call was classed as Category 2 - an emergency - but an ambulance did not arrive until 00:36, which was more than an hour later than the average response time for that category, the report said.
An investigation later found another ambulance had been available at 23:24.
Mr Wrightson added Nerams resources were allocated by the Emergency Operations Centre and it could not comment on the response time.
'Incorrectly categorised'
The first ambulance which arrived was a technician-led dual crew ambulance by third-party provider Nerams.
Shortly before 01:00 on 28 April an amber back-up request was made and a rapid response paramedic arrived at 01:07.
A third crew arrived at 01:36, but Mr Shields had already deteriorated into a cardiac arrest.
The report said the back-up request had been "incorrectly categorised by the crew" and Mr Shields required a higher priority back-up as he was "acutely unwell".
He died at about 02:27, despite "extensive resuscitation attempts", the report said.
'Evidence was clear'
Sunderland coroner David Place said there was a risk future deaths would occur unless action was taken.
"The evidence was clear that Jack's condition at the time of the first ambulance arrival at 00:36 was such that a higher priority back-up should have been requested," he said in his report.
"I am concerned that the crew should have recognised the deteriorating condition when considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a back-up request may have led to rapid stabilisation and transportation to definitive care."
Nerams has 56 days to respond to the coroner's concerns and outline what action it has taken or propose to take.