Source · Prevention of Future Deaths
Shaun Parks
Ref: 2023-0538
Date: 20 Dec 2023
Coroner: Katy Dickinson
Area: South Yorkshire (Western)
Responses identified: 0 / 2
View PDF
An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.
Date
20 Dec 2023
56-day deadline
14 Feb 2024 est.
Responses identified
0 of 2
Coroner's concerns
An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.
View full coroner's concerns
(1) The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.
(2) There were insufficient Emergency Medical Dispatcher's available to meet the forecasted demand. Staffing at YAS was below the requirement to meet the expected demand.
(3) There was a significant delay in offloading patients at hospitals, which tied up resources and meant they were unable to respond to emergency calls.
(2) There were insufficient Emergency Medical Dispatcher's available to meet the forecasted demand. Staffing at YAS was below the requirement to meet the expected demand.
(3) There was a significant delay in offloading patients at hospitals, which tied up resources and meant they were unable to respond to emergency calls.
Report sections
Investigation and inquest
On 25 May 2023 I commenced an investigation into the death of Shaun PARKS. The investigation concluded at the end of the inquest on 15 December 2023. The conclusion of the inquest was that Mr Parks died on 13 December 2022 at the Northern General Hospital in Sheffield, there was a significant delay in Mr Parks receiving treatment and this may have affected the outcome. His medical cause of death was recorded as: 1a Myocardial infarction (stented) 1b Ischaemic heart disease.
Circumstances of the death
Mr Parks attended Doncaster Royal Infirmary's Emergency Department on 12 December 2022 at roughly midnight, Mr Park's waited in the emergency department for approximately 1-1.30 hours until an ECG was carried out and showed Mr Parks to be suffering a heart attack. Mr Parks was moved to the resuscitation area of the department and an interfacility transfer request to the Northern General Hospital's primary percutaneous coronary intervention (PPCI) centre was made by a nurse at the hospital to Yorkshire Ambulance Service (YAS). It was confirmed by YAS that the category 2 blue light ambulance was booked at 3.06am on 13 December 2022, the ambulance should have taken at the latest 40 minutes to arrive, YAS confirmed the ambulance was categorised correctly as a category 2. The ambulance arrived at Doncaster Royal Infirmary at 06.29 hours and left scene to transfer to Sheffield's Northern General
Hospital's PPCI 06.44 and arrived at 07.15. Mr Parks deteriorated during his time at Doncaster Royal Infirmary and his procedure at Sheffield's PPCI unit commenced at 08.45. Mr Parks sadly died during the procedure at 10.17. There was a delay in the ambulance arriving to collect Mr Parks of 3 hours 18 minutes and 41 seconds.
Hospital's PPCI 06.44 and arrived at 07.15. Mr Parks deteriorated during his time at Doncaster Royal Infirmary and his procedure at Sheffield's PPCI unit commenced at 08.45. Mr Parks sadly died during the procedure at 10.17. There was a delay in the ambulance arriving to collect Mr Parks of 3 hours 18 minutes and 41 seconds.
Copies sent to
Yorkshire Ambulance Service, Brindley Way, Wakefield, WF2 0XGDoncaster Royal Infirmary, Thorne Rd, Doncaster DN2 5LTSheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU
Similar PFD reports
Related inquiry recommendations
Scottish Hospitals Inquiry
IPC role specifications and staffing levels
Muckamore Abbey Inquiry
Centralised workforce intelligence function
Muckamore Abbey Inquiry
Integrated workforce plans
Muckamore Abbey Inquiry
AHP and social care workforce recruitment
Fuller Inquiry
Ambulance data on conveying deceased
Infected Blood Inquiry
Transfusion Laboratory Staffing
Infected Blood Inquiry
Training in Transfusion Medicine
Manchester Arena Inquiry
Resolve paramedic-driver shortage in mass casualties
Manchester Arena Inquiry
LRF staffing and resources
Manchester Arena Inquiry
Ambulance Liaison Officer resourcing
Report details
- Reference
- 2023-0538
- Date of report
- 20 December 2023
- Coroner
- Katy Dickinson
- Coroner area
- South Yorkshire (Western)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Feb 2024 (estimated).
Sent to
- Department of Health and Social Care
- West Yorkshire Integrated Care System