Changes must be made to ambulance service according to coroner


Naomi Penrose

A CORONER concerned about the treatment of a pensioner who had to wait five-and-a half hours for an ambulance said “changes must happen and they must happen soon”.

Clive Harold Turner, 73, died at his home in Rossett in March.

He had waited five-and-a-half hours for an ambulance to be made available, before waiting a further two hours to be seen at Wrexham Maelor Hospital.

An inquest at Wrexham Guildhall yesterday heard reference made to the death of Flintshire man Fred Pring, who died at his home in Mynydd Isa, near Mold, in March 2013 after waiting 48 minutes for an ambulance.

Regarding Mr Turner, the inquest heard he had suffered with constipation in the week leading up to his death.

On March 25, an ambulance was called at 4pm after he was suffering pain. But it was not until 9.30pm that an ambulance was available.

A first responder paramedic arrived to Mr Turner one hour and 27 minutes after the initial 999 call and a healthcare worker stayed with him until the main ambulance arrived.

Mr Turner arrived at Wrexham Maelor Hospital just after 9.50pm but was not seen until almost midnight, by Dr Tatiana Rooney from the emergency department.

In evidence, Dr Rooney said Mr Turner’s main complaint was abdominal pain but he appeared comfortable and his pain score was recorded at two, which is deemed ‘mild’.

She said she had not asked if he had taken any pain relief as she relied on the ambulance for that.

That night an abdominal X-ray was ordered for Mr Turner, which found no signs of bowel obstruction. Dr Rooney diagnosed Mr Turner with constipation and during the early hours of March 26 discharged him from hospital.

But shortly before 1.25pm that day Mr Turner died at his home.

A post-mortem examination found he had a haemorrhage in his digestive tract.
Coroner John Gittins gave a narrative conclusion.

He said Mr Turner had been incorrectly diagnosed as constipated.

The cause of death was listed as a gastrointestinal haemorrhage, as a result of ischaemic bowel owing to atherosclerosis – or a clogging of the arteries.

Mr Turner had worked in engineering and as a ground catering manager at Liverpool and Everton football clubs.

At yesterday’s inquest, Mr Gittins referred to the inquest of Mr Pring, who died on March 21 last year after waiting 48 minutes for an ambulance.

At Mr Pring’s inquest in January, Mr Gittins said it could not be “established with certainty” if Mr Pring would have survived if the ambulance had arrived sooner.

But he said it was “probable” if it had arrived within eight minutes he would have lived long enough to be transported to hospital for further medical treatment.

He said the loss of even a single life to a potential delay was unacceptable and he was writing to the Welsh Ambulance Trust and Betsi Cadwaladr Health Board to tell them about his concerns that – unless action was taken – risks of deaths would continue.

The Welsh Ambulance Trust responded on March 19 – a week before Mr Turner’s death – saying problems with delays were being tackled.

During his conclusion, Mr Gittins said the situation cannot continue. He said: “I know from the evidence he has undoubtedly suffered in the hours leading up to his death, as a result of not being treated quickly enough.”

“Although the death was not as a result of that delay, I am concerned about that delay.

“Changes must happen and they must happen soon. My intention is to seek assurances from them (the Welsh Ambulance NHS Trust and Betsi Cadwaladr University Health Board) and to receive updates, tables and averages times of delays and handovers.”

Mr Gittins said Mr Turner’s case could be a “catalyst for change”.

The coroner said he would raise a regulation 28 report regarding Dr Rooney’s absence of knowledge regarding whether Mr Turner had been administered pain relief, as well as her absence of knowledge on the safeguarding of discharging patients.

A Betsi Cadwaladr University Health Board spokesman said: “We would like to express our sincere condolences to the family of Clive Turner. We fully accept the coroner’s verdict and will ensure the appropriate action is taken to address the issues raised at the inquest.

“We are working very closely with the Welsh Ambulance Service to minimise delays at emergency departments wherever possible.”

See full story in the Leader

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