Stroke victim died after waiting more than two hours for an ambulance

A coroner has blamed the crisis in the NHS and social care sector for delays in getting potentially life-saving treatment to a stroke patient.

Tony Reedman, 54, died four days after suffering a stroke while on holiday in Cornwall in June last year.

Cornwall Coroner’s Court heard Mr Reedman, from Norfolk, waited two and a half hours for an ambulance to take him from his holiday cottage to the Royal Cornwall Hospital in Truro.

Mr Reedman started feeling unwell on the evening of June 26 and his wife, Jill, dialled 999.

Call handlers suspected he was having a stroke and graded him as a priority two – meaning an ambulance should have reached him within the national target of 18 minutes.

He underwent surgery in hospital, but developed a cerebrovascular infarction and died four days later on June 30.

Guy Davies, assistant coroner for Cornwall, said the delay in the ambulance reaching Mr Reedman directly led to the delay in treatment starting at hospital, which could have saved his life.

“I find that the delay between the 999 call and Tony being taken to hospital significantly reduced his chances of surviving the blood clot,” Mr Davies said.

“The average stroke patient has a one in three chance of a positive outcome following treatment by thrombolysis in the first hour following a stroke.

“This is reduced down to one in 30 after four and a half hours. Tony’s stroke was more serious than the average.

“I find on the evidence it is not possible to definitively determine whether Tony would have survived if he had arrived at a hospital earlier and been treated earlier.”

Mr Davies said bed blocking in hospital due to failings in the social care sector had led to ambulances queuing outside hospitals in Cornwall unable to unload patients into A&E.

“I find that the ambulance delay was due to feedback through the healthcare system from the lack of social care provision in Cornwall,” he said.

“This lack of social care provision adversely affects both Royal Cornwall Hospital and the South West Ambulance in terms of the hospital being unable to discharge patients no longer needing hospital treatment due to the unavailability of social care beds or social care packages.

“As a result, the patients remain on wards when they should be discharged, and this leads to a lack of available beds in hospital wards for patients to be transferred to from accident and emergency.

“This in turn leads to congestion in accident and emergency which in turn leads to ambulances being unable to offload patients at the accident and emergency department and ambulances being held there – sometimes for longer than paramedic shifts, up to 18 hours according to our Royal Cornwall Hospital witnesses.

“Those ambulance delays give rise to a concern that circumstances creating a further risk of deaths will occur or will continue to exist in the future.

“In my opinion action should be taken to prevent or reduce those circumstances happening again of a risk of death created by them."

Mr Davies said the Senior Coroner for Cornwall, Andrew Cox, had already written to the Health Secretary with his concerns about the problems – highlighting several other recent inquests.

“In all of these deaths concerns have arisen regarding ambulance delays in Cornwall, which have in some cases significantly diminished patients’ prospects of survival,” Mr Davies said.

“Tony’s death has been amongst those that have been referred to the Secretary of State for action to be taken to reduce the risk of future deaths.

“I find that the delay in treatment for Tony was a direct consequence of ambulance delay.

“At the time of the triage the ambulance service had sufficient resources for the level of demand but there was no available ambulance to respond because available ambulances were detained at Royal Cornwall Hospital due to the inability to offload patients at the accident and emergency department.”

Mr Davies recorded a narrative conclusion and in addition to the report from the senior coroner, he would also be writing to NHS England with his concerns about the lack of a dedicated thrombectomy service in Cornwall.

The inquest heard patients in Cornwall needing the service at treated at Derriford Hospital in Plymouth but at the time of Mr Reedman’s death the service only operated Monday to Friday, from 9am to 5pm.

One doctor told the inquest: “It is a postcode lottery, and it is better to be in Bristol on a Saturday night than in Cornwall if you have a stroke because the services are not available here.”

The service has since been extended to weekends but is not operating 24/7 in Plymouth.