Death of Aaron Morris contributed to by ambulance service neglect, coroner rules

A widow has said she is "glad" the North East Ambulance Service has implemented changes after a coroner ruled the death of her husband was contributed to by ambulance service neglect.

Aaron Morris, a father-of-five, suffered a cardiac arrest in an ambulance which his wife Samantha was directing to hospital because the driver did not know the way, an inquest in Crook, County Durham, was told.

Mrs Morris, who was pregnant with twins at the time, was returning from a hospital appointment when she came across the scene of the crash, in which her husband’s Honda motorbike collided with a car at a junction.

She told ITV Tyne Tees: "He was amazing, he loved me, he loved life, he loved his children and tragically his life was put to a stop too early.

"He's got his children to live on in his memory and hopefully I can pass on his memory to them."

She continued: "It would be a tragedy for one of those incidents to happen in a incident but for multiple incidents to happen in one incident its beyond beyond comprehension."

Mr Morris, 31, died at the University Hospital of North Durham on 1 July 2022 at 6.40pm, after a crash which happened about six hours earlier in Esh Winning.

He died from chest injuries sustained in the crash, after which he was conscious and breathing but in serious pain.

During the inquest, coroner Crispin Oliver was told that it took 54 minutes for an ambulance to get to the scene because of high demand.

A private ambulance, run by the firm Ambulanz, was first to get to the scene, the inquest heard.

Mr Oliver said two experts found there was a tipping point before Mr Morris’s cardiac arrest in the ambulance, before which he would have probably survived had the correct medical intervention been available.

He had a cardiac arrest at 1.52pm, and one expert said the tipping point could have been as little as five to 10 minutes before it happened.

The coroner said witnesses from the institutions involved in the inquest had conducted themselves in a “humane” way at the hearings, and the organisations involved “showed themselves to be considerably chastened by their own review of the circumstances as to what happened”.

Outside the hearing, Mrs Morris said she welcomed the improvements made by the North East Ambulance Service and the Great North Air Ambulance Service (GNAAS).

She said: "I'm glad lessons have been learned, changes have already been implemented to prevent other families having to go through such a terrible experience.

She continued: "After hearing the evidence from Dr Noble, the medical director of the North East Ambulance Service, on preventing future deaths, I would now feel confident dialling 999 and requesting a North East ambulance, which I never thought I would be able to say again.

"I am disappointed that the third party ambulance provider Ambulanz didn't did not offer to sit down with me until this week to go through their lessons learned.

"Since then, they have not been in attendance, so that meeting has never taken place."

Mr Oliver heard during the inquest that one expert rated Mr Morris’s chance of survival as high as 95%, had he been treated in a timely manner.

The coroner also heard that an air ambulance could have been sent to the scene earlier, but that did not happen.

Mr Oliver was also told that a specialist paramedic known as a clinical team leader (CTL) should have gone to the scene, but she did not leave a meeting being held in Stanley.

The coroner said: “It is highly likely that Aaron Morris would have survived had available specialist medical treatment been applied in a timely manner.

“That it was not was due to a) delayed allocation of an ambulance deployed to the scene due to overstretched resources and b) failure of the ambulance service CTL to deploy to the scene at 12.52, when there was certainly enough information for her to do so.”

Mr Oliver concluded: “Aaron Morris died from injuries sustained in a road traffic collision and failure of the response of the ambulance service, contributed to by neglect.”

Dr Kat Noble, medical director for North East Ambulance Service, said: “Firstly, I would like to say to Samantha, and all of Aaron’s family that I am deeply sorry.

“When concerns were raised with us about Aaron’s care, we reported these as a serious incident and undertook a thorough investigation into what had happened.

“We shared the outcome of the serious investigation review with Aaron’s family.

“There were a number of organisations involved in this case and we unreservedly apologise for not providing the right care from our service when Aaron needed it.

“We accept that opportunities were missed to deploy a clinical team leader to this incident. This is the responsibility of the teams monitoring incoming and changing information about a patient’s condition, rather than one responder alone and we have made changes to our deployment processes to ensure that this couldn’t happen again.

“There were a number of other actions arising from the review of this incident that we have taken forward to improve the coordination of our response and we fully accept the coroner’s findings and conclusion.”

A GNAAS spokesperson said: "Our thoughts are with all those affected by this tragic event, we offer our sincere and heartfelt condolences to Aaron’s family and friends, and we are thankful his family now have answers.

"On this occasion, the injuries reported did not meet our dispatch criteria nor were we requested to attend; therefore the response efforts were managed by other emergency services.

"We will consider the findings of the inquest and review our processes to ensure we provide the best possible service.

"We remain committed to supporting our partners in emergency response, and continue to be on standby, ready to assist whenever our critical care services are required to provide urgent care to those in need."

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