Jack Shields

I am David Place, His Majesty’s Senior Coroner for the City of Sunderland

On 15 th January 2025 I commenced an Investigation into the death of Mr Jack Matthew Shields, who was born on 17 th May 1994 and who died at [REDACTED], Sunderland  on 28 th April 2024 aged 29 years. The Investigation concluded at the end of the Inquest on 25 th February 2025. The narrative conclusion of the Inquest was ‘Deterioration of a heart condition whilst an ambulance allocation was significantly delayed following a missed opportunity to assign an earlier available ambulance’. The medical cause of death was: – Ia Heart Failure II Aortic Dissection

Jack Matthew Shields was a 29 year old male with a past medical history outlining  extensive heart conditions. Jack had three previous open-heart surgeries including aortic dissection. On the evening of 27 th April 2024 Jack experienced shortness of breath, and his mother called 999 at 23:14hrs that night. This was categorised as Cat 2. Following a clinician  callback at 00:27am on 28 th April 2024 an ambulance was allocated at 00:31am and  arrived on scene at 00:36am. This was over an hour later than the national average  response time for Cat 2 patients. It later transpired after an investigation by NEAS following Jack’s death, that another ambulance had been available at 23:24am and, if allocated, would have arrived on scene at 23:36hrs on 27 th April 2024. At 00:52 on 28 th April 2024 an amber backup request was made, and a rapid response paramedic arrived at 01:07am. A third crew arrived at 01:36am, but Jack had already deteriorated into a cardiac arrest. The backup request was incorrectly categorised by the crew as Jack’s condition was clearly deteriorating, and he was acutely unwell due to  reducing blood pressure over a short time, tachycardia and an ECG revealed an ST- Elevated Myocardial Infarction. He required a higher priority backup. Jack died at his home address of [REDACTED], Sunderland despite extensive resuscitation attempts with his death declared at 02:27am on 28 th April 2024.

During the course of the Inquest the evidence revealed a matter 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 MATTER OF CONCERN is: – At 00:36am on 28 th April 2024 the first ambulance arrived at the scene, which was 1 hour and 22 minutes following the initial call being received. This was a technician led dual  crew ambulance provided by NERAMS – a third-party provider. The crew informed the  Emergency Operations Centre at 00:52am on 28 th April 2024 that an amber request for  paramedic assistance was required. A rapid response paramedic arrived at the scene at  01:07am on 28 th April 2024. Unfortunately, Jack deteriorated into a cardiac arrest and  despite resuscitative efforts, he was declared deceased at 02:27am on 28 th April 2024. The evidence was clear that Jack’s condition at the time of the first ambulance arrival at 00:36am was such that a higher priority backup should have been requested. Jack was  symptomatic of cardiogenic shock with descending blood pressures, shortness of breath, nausea and vomiting, and required the highest priority backup of Cat 1 (Peri Arrest). I am concerned that the crew should have recognised the deteriorating condition when  considering relevant observations such as ECG interpretation, an early recognition of such a deterioration and a correct categorisation of a backup request may have led to rapid  stabilisation and transportation to definitive care. I shall be glad to be told of any learning  arising from this death and timescales and results of your review.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.