A MAN who fell over and cut himself tragically bled to death after an ambulance took nine hours to respond to his call for help.
Peter Parker called 999 for an ambulance on September 10, 2021, at around 9pm, after he fell and cut himself on broken glass at home.
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He told the call handler he thought he had severed a vein and that blood was pumping out of his wrist.
Just three minutes into the call, while the handler was telling him how to halt the bleeding, they were suddenly disconnected.
The caller, from the Welsh Ambulance Service Trust, attempted to reconnect the call five times and conducted welfare checks, but all efforts were unsuccessful.
The call was flagged as an amber one priority, which meant it would be dealt with after red priority calls were cleared.
But during this time, Peter bled to death.
Coroner Aled Gruffydd issued a Prevention of Future Deaths report following the discovery of the body by emergency service crews on September 11, 2021.
A rapid response vehicle arrived at Peter’s home at 6:30am.
This police assisted in gaining access at 7am – around nine and a half hours after the ambulance was called for.
Peter was pronounced dead moments after they arrived, at 7:09am.
The coroner described how the inquest found that ambulances were stuck waiting at hospitals to hand over patients, which meant they were not free to respond to other calls.
Some ambulances were waiting 11 to 12 hours at the time, which is about the length of an average paramedic’s entire shift.
A system introduced in 2015 states that an amber call should be responded to within 20 minutes.
A person with a severed artery can bleed out and die in as little as two minutes.
Mr Gruffydd said in the report: “I am concerned that the response time in this case was beyond the expected survivability of such an injury.
“The amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question.
“I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose.”
How fast should ambulances arrive?
How quickly an ambulance has to get to you varies based on where you are and your cirumstances
In the UK, the target response times set by the NHS are generally as follows:
Category 1: Life-threatening emergencies (e.g., cardiac arrest) should receive a response within seven minutes.
Category 2: Emergencies requiring immediate intervention (e.g., strokes or severe burns) should have a response time of 18 minutes.
Category 3: Urgent but not immediately life-threatening situations (e.g., fractures) should be attended to within 120 minutes.
Category 4: Non-urgent cases may have longer response times, depending on resources.
These targets are all about getting medical help to patients quickly to improve their outcomes.
But real response times can be influenced by things like traffic, available resources, and the specifics of each call.
The coroner gave a conclusion following Peter’s death as a haemorrhage from a transected radial artery caused by a broken glass at home and contributed to by the significant delay in the arrival of the requested ambulance.
The time for survival of such injuries was 30-45 minutes, however, the time taken to respond was in excess of nine hours.
Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes.”
The report has been sent to the Welsh Ambulance Service, the Swansea Bay University Health Board and the Welsh Government.
They are expected to respond to the report with action they will undertake to prevent future deaths within 56 days.
‘DEEPLY SORRY’
Lee Brooks, executive director of operations at the Welsh Ambulance Service, said: “We were deeply sorry to hear about the death of Mr Parker and I would like to extend our thoughts and condolences to his family and loved ones.
“We take coroners’ recommendations very seriously and we will of course do all we can to respond to them.
“Pressures across the health and social care system are well-documented and the ambulance service is not immune to those pressures, which is why we are thinking about how we deliver ambulance services differently in the future.
“Currently, ambulance crews spend a large proportion of their time supporting patients outside emergency departments, which of course means that they are not able to attend other calls in the community.
“We’re actively looking at what we can do to use the skills of our people differently, to manage patients closer to home and make our emergency ambulances more readily available for patients like Mr Parker.
“While it’s never easy receiving a Prevention of Future Deaths report from coroners it’s important that we reflect on how we can accelerate our improvements and also collaborate further with health and social care partners to help deliver meaningful and lasting change and provide patients the care that they deserve.”
