An Inquest has ruled that the death of a man from Sheffield was due to the neglect of the Yorkshire Ambulance Service after he waited almost an hour for paramedics when his 999 call went incorrectly categorised.
Specialist solicitors from Medical Solicitors were at Sheffield Coroners' Court to support the family of Mark Taylor who died in October 2022.
The inquest heard how 62-year-old Mark was experiencing severe chest pains and difficulty breathing. His wife of almost 20 years, Carole, called 999 at 1.09pm to request an ambulance. It took over four minutes for that call to be answered. Carole was asked by the call handler whether her husband was breathing, to which she replied “Yes, just.”
The handler incorrectly logged the call as category two, ‘serious but not life threatening’ placing Mr Taylor in a lengthy queue of patients. However, giving evidence, James Goulding, the ambulance service's clinical response and governance manager, said this should have been deemed a report of "ineffective breathing" and logged as a category one call for ‘immediate threat to life’.
This would have led to an ambulance being dispatched immediately and arriving about ten minutes later.
Instead, it took 58 minutes for the ambulance to arrive, and not before the family had called 999 again in distress when Mark became unresponsive. Carole’s daughter, Tyne, administered CPR whilst they were waiting for the ambulance to arrive which gave him a fighting chance.
However, by the time paramedics arrived at 2.07pm, Mark was in cardiac arrest. He was taken to Northern General Hospital in Sheffield, near to his home in Shiregreen, where he had another six cardiac arrests. He sadly died the following day.
The hearing also included evidence from the interventional cardiologist who treated Mark at hospital, who said it was "more likely than not" he would have survived if paramedics had reached him before he went into cardiac arrest.
A 'gross failure'
Recording a narrative conclusion, the assistant coroner, Nathalie James, said the delay in responding to Carole’s call had been a "gross failure" by the ambulance service. She added, “Had the call been correctly categorised, the ambulance would have arrived before he went into cardiac arrest. This could have prevented the cardiac arrest, and therefore his death. His death was contributed to by neglect.”
Mr Goulding apologised to the family on behalf of the ambulance service and said that particular day the YAS had been under “extreme pressure”.
In a statement read out from outside the coroners’ court on behalf of the family, Medical Solicitors’ director, Matthew Brown said: “We have heard today that delay in answering emergency calls has been identified as a national issue which suggests that the ambulance service is inadequately resourced. Sadly, we have noticed an upward trend in cases where ambulance and 999 performance has led to avoidable harm to patients and threat to life.
"Today’s finding of neglect reflects the seriousness of the failings in Mark’s care. Mark had the support of his large and loving family throughout his life, and they take comfort from the fact that they were with him when he died.”
Legal proceedings
Carole is bringing a claim for clinical negligence against the Yorkshire Ambulance Service NHS Trust as she believes that, had it not been for the delay of the ambulance service in getting to her husband, he would still be alive. Her case is being handled by our solicitor, Miriam Bi.