Kevin Woods

I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly.

On 19 January 2024 I commenced an investigation into the death of 64-year-old Kevin Woods. The investigation concluded at the end of the inquest on 30 September 2024. The medical cause of death was found as follows: 1a. Hypertensive heart disease The four questions – who, when, where and how – were answered as follows: Kevin George WOODS died on 17 January 2024 at [REDACTED] from complications of an undiagnosed heart condition following an ambulance delay which denied Kevin the opportunity of potentially lifesaving  treatment. Kevin’s family made a 999-call requesting an ambulance at 22:24 hours on 16  January 2024, at which time Kevin was exhibiting clear symptoms of a heart attack.  The ambulance service allocated Kevin a category 2 priority but there were no ambulances available on that category. Kevin went into cardiac arrest at 02:33 hours on 17 January 2024 and subsequently became unresponsive.  The ambulance service re-categorised the call as category 1 and despatched an ambulance. A Paramedic Support Vehicle arrived at 02:44 hrs on 17 January 2024 whilst the  family were giving Kevin CPR.  The paramedics continued CPR but were unable to save Kevin’s life.  Kevin was pronounced deceased at the scene at 03:31 hrs that  day. There was a response delay of 4 hours and 16 minutes from the original category 2 priority decision to the arrival of the paramedic support vehicle. Kevin’s heart condition was possibly treatable, and the ambulance delay denied  him the opportunity of potentially lifesaving treatment. The ambulance delay was attributable to a systemic failure related to the whole system of health and social  care. The narrative conclusion of the Inquest was as follows: Kevin died from an undiagnosed and possibly treatable heart condition, following  an ambulance delay attributable to a systemic failure related to the whole system of health and social care. The ambulance delay was possibly causative of death in that it denied Kevin potentially lifesaving treatment .

The findings of fact on how Kevin died are set out above in the answers to the four statutory questions. Systemic failure and Kevin’s death

On the day the ambulance call was made there were considerable ambulance  delays. Whilst Kevin’s priority remained category 2, during the period from the  original 999 call to the onset of cardiac arrest (over four hours) there were no  ambulances available for Kevin.

The national target set by the Department of Health is to attend Category 2  incidents within 40 minutes on at least 90% of occasions, with an average response of 18 minutes.  Kevin waited over four hours and the reason the  ambulance then attended was because Kevin’s case was re-prioritised to Category 1 following the cardiac arrest.

Data provided to the court suggested that on the 16 th January 2024 some Category 2 calls were having to wait 6 hours for an ambulance.

At approximately the time the ambulance call was made, 23:00 hours, there were 33 incidents awaiting allocation in Cornwall, including 20 that were Category 2. At  this time South West Ambulance Service Trust (SWAST) reported that all  ambulance resources were either responding to calls or delayed at hospitals (in the patient handover process). At the two main receiving hospitals for Cornwall, there  were 12 ambulances delayed at Plymouth hospital and 22 ambulances delayed at  Truro Royal Cornwall Hospital (RCHT).  At this time SWAST was 123% resourced  for anticipated demand in Cornwall, with a total of 45 ambulances available. This  means approximately half of the allocated ambulances for Cornwall were delayed at RCHT.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will 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) Continuing average handover delays (and therefore response delays) which  create a risk of future deaths . The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality. 2) There is a direct connection between the risk of ambulance delays and  inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall . This is because the  inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of  future systemic failures causing ambulance delays. 3) There is no single organisation with responsibility to ensure that the  provision of social care is sufficient to avoid delayed discharges leading to  ambulance delays . The obligation upon local authorities such as Cornwall Council is limited to a requirement to promote the market. 4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays . The organisations immediately  required to deal with ambulance delays do not have control over the services  primarily responsible for the delays.

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.