Peter Parker: Prevention of Future Deaths Report

Emergency services related deaths (2019 onwards)Other related deathsWales prevention of future deaths reports (2019 onwards)

Skip to related content

Date of report: 22/10/2024 

Ref: 2024-0565 

Deceased name: Peter Parker 

Coroners name: Aled Gruffydd 

Coroners Area: SWANSEA NEATH & PORT TALBOT   

Category: Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards) | Other related deaths

This report is being sent to: SWANSEA BAY UNIVERSITY HEALTH BOARD | WELSH AMBULANCE SERVICE NHS TRUST | WELSH ASSEMBLY GOVERNMENT   

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:  

CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY  
BAGLAN ENERGY PARK  
BAGLAN 
PORT TALBOT  
SA12 7BR 

CHIEF EXECUTIVE WELSH AMBULANCE SERVICE NHS TRUST BEACON HOUSE 
WILLIAM BROWN CLOSE 
CWMBRAN 
NP44 3AB 

[REDACTED], DIRECTOR GENERAL FOR HEALTH AND SOCIAL SERVICES WELSH ASSEMBLY GOVERNMENT 
CATHAYS PARK 
CARDIFF 
CF10 3NQ 
1CORONER

I am Aled Gruffydd, Acting Senior Coroner, for the coroner area of SWANSEA NEATH & PORT TALBOT 
2CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
3INVESTIGATION and INQUEST

On the 20th September 2021 I commenced an investigation into the death of Peter Parker. The investigation concluded at the end of the inquest on the 16th October 2024.

The medical cause of death is:
1a) haemorrhage from sharp force injury to right wrist including transection of right radial artery. 
1b)         
1c)         


The conclusion of the inquest as to how Mr Parker came to her death was a narrative conclusion and is as follows:- 

The deceased died of a haemorrhage from a transected radial artery caused by broken glass at home, contributed to by the significant delay in the arrival of the requested ambulance.
4CIRCUMSTANCES OF THE DEATH

The deceased was Peter Parker who was pronounced dead on the 11th of September  2021 at his home address of [REDACTED]. The cause of death was a haemorrhage from sharp force injury to right wrist including transection of right radial artery.

Peter sustained a laceration injury to his right wrist whilst at home after falling and cutting himself on broken glass. Peter dialled 999 for an ambulance at 9:19pm on the 10th of September 2021 and stated that he had cut a vein and blood was pumping out.  Approximately 3 ½ minutes into the call, the line disconnected at the time when the call  handler was attempting to give Peter advice on how to suppress the bleeding. The call- handler for The Welsh Ambulance Service Trust (WAST) made five attempts to  reconnect the call and make welfare checks without success. The MPDS system in operation by WAST gave the call an Amber 1 priority meaning that the call would be dealt with in order of receipt after all the Red priority calls were cleared. The requested  rapid response vehicle arrived at Peter’s home at 6:30am on the 11th of September 2021 and with the assistance of Police access was gained to Peter’s home at 7:00am. This  was approximately 9 ½ hours after the ambulance was requested. Peter was pronounced deceased at the scene at 7:09am.  
5CORONER’S CONCERNS

During the course of the inquest the reason given for the significant delay to respond to  the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The  longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system  was introduced in 2015 it was envisaged that an Amber 1 priority call would be  responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for  Peter to transport himself to hospital, and Peter had not contacted his family for their assistance. 

I am concerned that the response time in this case was beyond the expected  survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but  was inappropriate in the context of the time taken to respond to such priorities on the  evening in question. I am further concerned that the reason for the delay was due to  ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose. 

The MATTERS OF CONCERN are as follows. –

1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of  such injuries was 30-45 minutes, however the time taken to respond was in  excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was  envisaged that when the system was introduced such calls would be responded to in 20 minutes. 
6ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action.  
7YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 December 2024. I, the coroner, may extend the period. 
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. 
8COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED].
  
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary  form. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 
922 October 2024
[SIGNED BY CORONER]