Sandra Savage

Date of report: 14/09/2026 Ref: 2026-0434 Deceased name: Sandra Savage Coroner name: James Bennett Coroner Area: Birmingham and Solihull This report is being sent to: West Midlands Ambulance Service REGULATION 28: PREVENT FUTURE DEATHS REPORT

I am James Bennett HM Assistant Coroner for the coroner area of Birmingham and Solihull.

14 September 2026

1. Chief Executive, West Midlands Ambulance Service

You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 November 2026 . I, the coroner, may extend the period if an appropriate  application is made.

Your response must contain details of action taken or proposed to be taken, setting out  the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any  representations regarding the publication of your response. These representations  should be made at the same time as the response is provided. I will pass any  representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for  sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the  Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports – Courts and Tribunals Judiciary. 6 SUMMARY OF THE CORONER’S CONCERN West Midlands Ambulance Service have not conducted any form of learning  investigation under the Patient Safety Incident Response Framework. The evidence  revealed there is likely to be some important learning around assessing the threshold for admitting to hospital a patient who has fallen with reported rib injuries.

In my opinion unless action is taken to address the above concerns then there is a  significant risk of future deaths and I believe you have the power to take such action.

On 29 January 2026, I commenced an investigation into the death of Sandra  Yvonne Savage, aged 73 years. The investigation concluded at an inquest.  The medical cause of death was 1a  Haemorrhage, Traumatic right-sided haemothorax 1b  Rib fractures following a fall 1c 1d II  Dementia, Severe frailty, Previous cerebrovascular accident How, when and where Sandra was admitted to a psychiatric ward in December 2025 subject to Section 2 of the Mental Health Act relating to her advanced dementia. The section expired on  11/01/26. She was at high risk of falling. Around 00:50hrs on 16/01/26 she fell when  attempting to sit in a chair hitting her right ribs. The duty doctor advised admission to  hospital for a chest x-ray suspecting a rib injury. Paramedics attended at 03:22hrs and  their clinical assessment was that Sandra did not require admission to hospital finding  no clear traumatic injury and respiratory observations within normal parameters.  Around 12:30hrs a second doctor again advised Sandra required hospital admission due to right sided swelling and rib pain. The ambulance service was very busy and  paramedics arrived at 07:30hrs on 17/01 and Sandra was admitted to the Queen  Elizabeth Hospital Birmingham. An x-ray confirmed minimal traumatic right sided rib  fractures but with associated haemothorax impacted by blood thinning medication. She was frail and passed away peacefully around 06:25hrs on 18/01/26. It is not clear that  earlier admission would have changed the outcome. Conclusion Death was the consequences of an accidental fall, contributed to by blood thinning medication.

As above.

During the course of the inquest I heard evidence 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: The evidence revealed a material disparity around the threshold for admitting a patient  to hospital who had fallen with reported rib injuries. Two doctors at the psychiatric unit  separately advised the patient needed hospital admission because of potential rib  injuries, and a Consultant Thoracic Surgeon gave evidence that the real need for hospital admission is the potential for internal bleeding caused by rib fractures. All three doctors felt the threshold for hospital admission was met. On the available evidence it  was difficult to reconcile how the attending paramedics at 3:22hrs 16/01/26 came to a  different view. In deciding the threshold for hospital admission was not met, the concern is that they  did not give adequate consideration/weight to (1) admission had been advised by a  doctor, (2) the patient had dementia and may not have been able to communicate  effectively, (3) by the time of their arrival pain relief may have masked the real pain, (4)  she was taking blood thinning medication, and (5) linked, the real concern is of internal  bleeding rather than just rib fractures. Linked, when a second doctor repeated hospital admission was required, the concern is the triage did not appreciate the seriousness and the second ambulance did not arrive for 15+ hours delaying hospital admission.  West Midlands Ambulance Service had been informed of the death by the coroner at an  early stage. No learning investigation had been conducted. They were not represented at the inquest. My principal concern is West Midlands Ambulance Service have not conducted any form of learning investigation under the Patient Safety Incident Response Framework  and the evidence revealed matters of concern indicating there is likely to be some  important learning that may prevent future deaths. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every interested person who in my opinion  should receive it. I also may send a copy of the report to any other person who I believe may find it useful  or of interest. I can confirm I have sent the report to:

1. Family.
2. Mental Health Trust.
3. Alzheimer’s Society.

I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any  representations will be sent to the Chief Coroner alongside the report. Please refer to  box 4 above for additional information relating to the publication of  reports and  responses. 12 SIGNATURE [REDACTED]  James Bennett Assistant Coroner for Birmingham and Solihull