Daniel Forrest

On 07 October 2025 I commenced an investigation into the death of Daniel Charles FORREST aged 85. The investigation concluded at the end of the inquest  on  11  June  2026.  The  conclusion  of  the  inquest  was  that: Daniel Charles Forrest died on 1 October 2025 at East Surrey Hospital, 1 Canada Avenue, Redhill, Surrey from an unsurvivable head injury. He had a witnessed fall outside his home address falling onto a curb on 30 September 2025. An ambulance was called but due to a significant delay was cancelled by Mr Forrest before they attended. There is insufficient evidence from which I can conclude that this contributed to the death. He then had an unwitnessed fall  at  his  home  address  on  1  October  2025  when  emergency  services attended and conveyed him to hospital where he sadly died.

Mr Forrest was an 85-year-old gentleman who fell outside his home at around 17:12 hrs hitting his head on a curb. A bystander called Southeast Coast Ambulance Service NHS Foundation Trust (“SECAMB”) at that time but his son and daughter-in-law were also present. The call was triaged using the NHS  Pathways  system  which  concluded  that  he  needed  a  Category  3 response which at that time had a target response time of 120 minutes. The contact details of the family members who were present with Mr Forrest were taken. At the time of the call being made SECAMB was in Clinical Safety Plan level 3. The Pathways call closing script told the Emergency Medical Adviser who took the call on behalf of SECAMB that they should tell the caller that “an ambulance  was  being  arranged”  which  they  did.  In  addition  to  the  NHS Pathway  script,  the  Emergency  Medical  Adviser  told  the  caller  that  the estimated time of arrival for the ambulance would be 3 hours and 47 minutes.

An ambulance was not dispatched at that time as category 3 calls then are validated by clinicians before being added to the dispatch queue. Clinicians attempted to call back for this reason but were unable to make contact as only the contact number of a bystander rather than the family with Mr Forrest was identified on the CAD system. The callbacks were attempted at 20:42 and 21:02. As such the call was added to the dispatch queue 21:05 hours but there was no ambulance available to be allocated to Mr Forrest due to the significant number of calls outstanding in higher categories for response and earlier timed calls in category 3.

At 21:48 the family called SECAMB as there had now been 4 hours and 36 minutes since the initial call. The Emergency Medial Adviser did not re-triage the call and therefore no updated estimated time of arrival for the ambulance was  provided.  At  that  time  the  Emergency  Medical  Adviser  did  discuss whether Mr Forrest could self-convey to hospital and worsening care advice was                         given.

At 23:45 the family called SECAMB again to cancel the Ambulance as Mr Forrest wanted to go to bed and they had been waiting for 6 hours and 33 minutes. He spoke directly with SECAMB and the call was closed by SECAMB after clinical review. The family indicates that they would be staying with Mr Forrest.

Around 01:20 on 1 October 2025 the family found Mr Forrest had fallen in the house and sustained further injury. SECAMB were called and the call was triaged using the NHS Pathways system as a category 3 response. At that time, there were 138 calls outstanding including 20 category 2 calls and 110 category 3 calls outstanding. An estimated time for attendance was requested by the family but this was not produced. Worsening care advice was given.

At  02:06  Mr  Forrest  had  deteriorated  and  therefore  the  family  contacted SECAMB again and the call was re-triaged with the additional new symptoms as category 2. The ambulance arrived to assist Mr Forrest at 02:23 on 1 October and he was conveyed to hospital.

Sadly he was found to have an unsurvivable head injury from which he died later that day.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.