A former senior Army officer died after waiting for nearly five hours in the back of an ambulance stuck outside a hospital because there was no bed for him, an inquest has heard.
Col John Codd, 88, died in the Royal Cornwall Hospital, in Truro, on Jan 16 this year after suffering a fall as he got out of a taxi which was returning him to a nursing home in St Austell.
Cornwall Coroner’s Court heard an ambulance took more than two hours to arrive after Col Codd fell on to the ground outside the home at 12.30pm earlier that day.
He arrived at the Royal Cornwall Hospital at 4.30pm but was not admitted until 9.11pm because no bed was available inside, despite an ambulance handover target of just 15 minutes.
In the meantime, he was taken in and out of hospital for various checks. As he waited inside the ambulance, he was brought into the hospital to be triaged by a nurse at 5.47pm and then examined by a consultant at 6.10pm.
An X-ray was taken for a suspected fractured hip and at 8pm, Col Codd was reviewed by a junior doctor, who then ordered a CT scan of his pelvic area.
Finally admitted at 9.11pm
At 9.11pm, Col Codd was finally admitted to the hospital and placed in the “majors” area of the department.
An hour later, he was found on the floor with breathing difficulties having suffered a cardiac arrest, from which he could not be resuscitated.
The ambulance reached Col Codd at 2.49pm – more than two hours after he had fallen – as he lay on the ground covered in blankets.
A post mortem examination found Col Codd had suffered a fracture to the cup of his right femur and had developed a rare rectus sheath haematoma from the earlier fall, which was the cause of his death.
He had pre-existing atrial fibrillation – an irregular heartbeat – and changes in his blood pressure noted during medical reviews by doctors in the emergency department were attributed to this rather than the haematoma.
Hold-ups in handing over patients
A report into Col Codd’s death by the South Western Ambulance Service NHS Foundation Trust said delays in reaching him had been because of the hold-ups in handing over patients at hospital.
Andrew Cox, the senior Cornwall coroner, recorded a narrative conclusion and said he would be writing to the health secretary to raise his concerns about delays in the system.
Dr Aaron Green, an emergency department consultant at the trust, said that if the system had been working properly then Col Codd would have been seen by a doctor within an hour and the CT scan would have probably been ordered earlier.
“There was a delay in the arrival of an ambulance and a further delay in his subsequent admission into hospital,” he said.
“It is probable that an earlier admission into hospital would have resulted in an earlier CT scan being performed that would have revealed the presence of the haematoma.
“It is possible that if a blood transfusion had taken place, the death would not have occurred when it did.”
Delays ‘an ongoing problem’
Dr Green said those delays had been an ongoing problem.
“It has been an ongoing problem in many departments across the country, particularly in Cornwall, for many years,” he told the inquest.
The inquest heard that for the six months to January, delays in admitting patients to a ward or sending them home totalled 24,000 hours at the hospital – the equivalent of shutting 32 emergency department cubicles for a whole month.
The coroner said he had previously raised concerns with the hospital and ambulance trusts about handover delays.
‘In the wrong place at the wrong time’
“The problem is the ambulances in the wrong place at the wrong time – they are parked outside the emergency department at Truro [and] can’t then respond to a call,” he said.
The coroner said there had also been delays in discharging patients back into the community due to a lack of social care or beds in community hospitals.
“This is why I wrote to the secretary of state for health saying this was a systemic issue. It is not a problem that lies at the door of the South West Ambulance Trust or the Royal Cornwall NHS Trust. It is across the system,” he said.
“Unless we get the flow of patients through the hospital, it bottlenecks in the emergency department.”
When asked for his view of this, Dr Green replied: “I would agree wholeheartedly.”
Source Agencies
