Mark Bennett

I am the Assistant Coroner for the area of South Yorkshire (West)

On 12.12.22, I commenced an investigation into the death of Mark Bennett aged 38 The investigation concluded at the end of the inquest on 19.09.23 The conclusion of the inquest as to the medical cause of death was: 1a Pulmonary Embolism 1b Deep Vein Thrombosis 1c Immobility in relation to leg injury I answered the statutory questions as follows: Mark Bennett died on 14.04.22 at Meadowhall Shopping Centre Sheffield from a pulmonary embolism following a sprained ankle sustained in a trip on stairs in the London Underground on 05.04.22. There was a delay in the ambulance attending Mark caused by pressures on the ambulance service and an error in ambulance allocation. I recorded a short form conclusion of accidental death

Mark tripped in the London underground on 05.04.22 causing damage to his ligaments in his right ankle. He was initially treated in the Royal Free Hospital, London and then had an outpatient appointment at his local hospital of Diana Princess of Wales Hospital in Grimsby, near to  where he lived, on 11.04.22 . Mark collapsed with a suspected pulmonary embolism causing a cardiac arrest in the Meadowhall Shopping Centre Sheffield on 14.04.22. During evidence of [REDACTED] for the Yorkshire Ambulance Service (YAS) in the inquest on 19.09.23, it emerged that paramedics attempted resuscitation of Mark for only 21 minutes. This was just within their then applicable protocol. Rather than transport Mark to the nearby accident and Emergency Department of the Northern General Hospital Sheffield, they declared ROLE and no further attempts a resuscitation took place. Concern was expressed that this meant that there was no opportunity for thrombolysis to be attempted by hospital staff . [REDACTED] of YAS gave evidence that the guidance and protocols available for ambulance staff/paramedics on when to stop resuscitation and/or take to hospital for attempts at thrombolysis in these circumstances were unclear. I was concerned that this lack of clarity on what constituted best practice on this issue for paramedics and/or ambulance staff might place future patients at risk in similar situations

The MATTERS OF CONCERNS are as follows: I believe there is a lack of guidance and/or protocols on what constitutes best practice on this issue for paramedics and/or ambulance staff which might place future patients at risk in similar situations. In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.