Source · Prevention of Future Deaths

Rita Taylor

Ref: 2023-0026Deceased Date: 25 Jan 2023 Coroner: Tom Osborne Area: Milton Keynes Responses identified: 0 / 1 View PDF

Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical deterioration in a patient's condition while awaiting transport.

Date 25 Jan 2023
56-day deadline 22 Mar 2023 est.
Responses identified 0 of 1
Emergency services related deaths (2019 onwards)

Coroner's concerns

AI summary
Insufficient ambulance resources in Milton Keynes caused severe and prolonged delays in emergency response, leading to a critical deterioration in a patient's condition while awaiting transport.
View full coroner's concerns
I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes. The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. |At that time there were "no available resources to send." At 11.12 a 999 call was made by a passer by but there were still "no available resources ". At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ". At 12.41 a call was made to Mrs. Taylor's location but there were " still no available resources to send" At 13.12 A further 999 call was made " awaiting resources to become available" At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources". At 14.42 further 999 call but again "no available resources". At 15.25 Case reviewed to a category 2. At 16.29 An ambulance was despatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade. Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Comma score was recorded as 3.She died later the same day.

Report sections

Investigation and inquest
On 07 October 2022 I commenced an investigation into the death of Rita Maureen TAYLOR aged 84. The investigation concluded at the end of the inquest on 17 January 2023. The conclusion of the inquest was that: The deceased suffered an unwitnessed fall at her home, 43 Dodkin, Beanhill, Milton Keynes and suffered a head injury. An ambulance was called at 10.28 but due to lack of resources did not arrive until 17.17. When she arrived at Milton Keynes University Hospital at 17.58 her Glasgow Comma Score was 3. A CT scan revealed a large intracerebral bleed. She died the same day at the hospital. The delays in sending an ambulance resulted in a number of lost opportunities to admit her to hospital and begin her treatment.
Circumstances of the death
As outlined above and in Coroner’s concerns

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Report details

Reference
2023-0026Deceased
Date of report
25 January 2023
Coroner
Tom Osborne
Coroner area
Milton Keynes

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Mar 2023 (estimated).

Sent to

Department of Health and Social Care

Part of a series

2 reports
2018-0225 1/3

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