Susan Dear

[REDACTED], Secretary of State for Health and Social Care

I am Hannah Godfrey Area Coroner for the coroner area of Berkshire

On 23 May 2024 I opened an inquest into the death of Mrs Susan Dear on 4 January 2023 aged 72. The inquest concluded on 9 September 2024. The family requested that I refer to Mrs Dear as Susan, which this report will reflect. The conclusion of the inquest was that Susan had died of natural causes (Pulmonary Embolism due to underlying Deep Vein Thrombosis).

Susan was suffering abdominal pain, and her family called 999 at 10.20 pm on 3 January and that call was triaged at category 3 (meaning that an ambulance was expected to be on scene within 120 minutes). At that time the inquest heard that there were 48 patients awaiting ambulances, 7 were waiting for category 2 ambulances with the longest wait time being 1 hour 12 minutes,  19 patients were waiting for category 3 ambulances with the longest wait time being 7  hour 55 minutes. Susan’s symptoms deteriorated and a second 999 call made at 2.32 on 4 January was triaged at category 2 (meaning that an ambulance was expected to be on scene within 40 minutes). At that time the area was in OPEL 4, the highest OPEL level, indicating Extreme  Pressure on resources. There were 37 patients waiting for ambulances. 9 patients  were awaiting category 2 ambulances with the longest wait being 5 hours 53 minutes, and 26 patients were awaiting Category 3 ambulances, with the longest waiting time  being 14 hours 39 minutes. There was no ambulance resource available to respond at any time to Susan. At around 5 am Susan’s family decided they could wait no longer and drove her to hospital, where she was recognised as deceased shortly after arrival at 6.02 am. On the evidence at inquest I did not find that the ambulance delay contributed to Susan’s death.

During the course of the investigation and inquest the evidence revealed matters giving  rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) South Central Ambulance Service (‘SCAS’)’s internal investigation established that there had been no missed opportunity to send an ambulance during the time that Susan was waiting overnight on 3 to 4 January 2023 as none was available; and (2) overnight between 3-4 January 2023 patient’s lives were put at risk because SCAS did not have ambulances available to meet the level of demand resulting in severe delay and ambulance response times far outside the national expected standards; and (3) this was not unprecedented but was reflective of a picture of a chronic situation whereby there was a continuing risk that demand for emergency ambulances would outstrip resources and SCAS were unable to reassure me this was a situation that had been resolved; and (4) SCAS have an SCAS wide improvement programme which is aimed at increasing capacity, which is monitored by NHS England and the Trust’s own commissioners. There was no evidence indicating anything that it was within SCAS’s power to change on this occasion; and (5) SCAS’s service was operating at under the number of planned staff for that night, (despite the service taking all reasonable steps to meet requirements) due to chronic understaffing of the service with recruitment and retention issues with paramedic and other emergency response staff that the inquest heard are problems nationally; and (6) handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community; and (7) resources were being wasted due to ignorance of some of members of the public engaging with the service, and the inquest heard that it was unlikely this  would improve substantially without a programme of public education regarding when it is appropriate to call 999, and when it is not.

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.