A devastated wife whose husband died after an hours-long ambulance wait while throwing up and writhing in pain says she is both angry at and distraught with at the system. Nicola Waters called 999 for an ambulance at 2.37am when her husband – who never complained of pain or illness – found himself trembling, throwing up and in severe chest pain in the early hours of May 24, 2024.
Andrew ‘Andy’ Waters, 56, from Cornwall, died at Royal Cornwall Hospital after being admitted from a heart attack despite the best efforts of all those involved in his emergency care from the moment he arrived. It was found at an inquest on Thursday (March 13) that if it wasn’t for the ambulance delay caused by “systematic” and nationwide NHS problems he may still be alive and with his family.
The inquest hearing was held at Cornwall’s Coroners Court in Truro for three hours during which it was explained Mr Waters, known as Andy, who was a fit and healthy man outside of having an unknown heart condition, had been in agonising pain on the evening of May 23, 2024, following days of worsening chest pain he initially treated as indigestion.
His wife called 999 in the early hours of the morning reporting pain in his chest, numbness in his arms, sickness and later trembling. The call was triaged and deemed a Category 2 call, the second most serious for the South Western Ambulance Service NHS Foundation Trust (SWASFT).
The only more serious category would be Category 1, which is for calls relating to patients with immediately life-threatening and time-critical injuries and illnesses, which Andy was not deemed to be at the time.
Mrs Waters made sure to clarify on the phone that it must be serious though as Andy had never complained of being ill or in pain and said she thought it was his heart. Told to call back if things worsened, she did and told them “the pain was becoming unbearable”.
She was told he was still on the list and an ambulance would be there as soon as possible. She said he was “writhing” on the floor in pain at this point, being sick and had constant tingling.
She was advised to get a defibrillator from the local garage but on arrival realised she needed a code which she had not been given and didn’t have her phone on her so had to leave it behind. By the time she returned home, Andy had deteriorated more and she could not leave his side.
Mrs Waters was called back by a navigation assistant at SWASFT, two hours after her initial call, who failed to have someone conduct a clinical triage to see if Andy’s condition had worsened and the category may have changed. A taxi was arranged at 4.40am by the ambulance service but the driver was not made aware it was an emergency and was distressed about this on arrival.
Once Andy arrived at Royal Cornwall Hospital at 5.37am (three hours after the first call) he suffered a heart attack and the medical staff jumped into quick action, performing numerous procedures in an attempt to save his life including emergency heart surgery. They sadly could not save him but Mrs Waters said she could not fault the medical staff once they had arrived.
“Andy was so healthy and he was never ill and I think he deserved so much better from our health services,” she said in a statement of the delay. “I am angry, I am sad and I don’t believe this should have happened. To have been sent a taxi is disgusting.”
An investigation by the coroner, Guy Davies, found that seven ambulances were queuing outside of the hospital waiting to offload patients at the time of Andy’s admission and that in total there were 84 patients in the hospital who were clinically well and should have been discharged but could not be due to known nationwide problems with bed blocking and community care problems. This means there are not enough care packages and care home placements for those patients resulting in ambulances being held up in hospital car parks with patients awaiting available beds.
Paul Graham, investigations officer within SWASFT, explained that at the time of the initial 999 call there were already 18 other Category 2 patients awaiting an ambulance in addition to Andy. He said “major delays” were reported at local hospitals at the time and it was an ongoing problem.
Mr Graham detailed some failings including that there should have been a further clinical triage before sending the taxi to take Andy to hospital. He said it may have been possible to upgrade the triage to a Category 1/2 at this time, in between the two most serious. This would have at least bumped Andy to the very top of the Category 2 list.
Mrs Waters read a statement through tears to the courtroom in which she told those present “my husband is not a number”. She said he deserved so much more than a taxi ride to hospital, hours after calling 999.
“The loss of my husband has devastated my family in every way. I take drugs to calm my panic attacks. I take drugs so I can sleep and I take drugs for the flashbacks which I have no control over. Half of me is so angry and the other half is so desperately sad.
“I honestly don’t know what I expect today, my only hope is that I get answers to my questions and someone takes responsibility, even if it ends up being my fault.”
Mr Graham gave Mrs Waters an apology on behalf of SWASFT and said the service should have had an ambulance there but it was a matter of fact that the reason an ambulance couldn’t be there was because of a much larger, systematic problem within the NHS. He also reassured her that it was absolutely not her fault and she remained calm throughout the calls and did all she could for her late husband.
He finally added that the call handler who made a human error during the third call-in, in that it was not transferred to a human clinician for assessment, no longer works for SWASFT but did not clarify the reasons why.
“[Andy] shouldn’t have had to wait that long but unfortunately that is the state of the trust at the moment,” he added. Mr Davies concluded that there has been a “systemic failure” in health and social care which has led to ambulance delays and subsequently Andy’s death.
Mr Davies said there were procedures available that likely would have saved Andy’s life but due to the cardiac arrest which occurred on arrival at the hospital his chances were “massively diminished” by the delay in getting him there.
He will be issuing a Prevention of Future Deaths report as he feels there is a risk of further deaths in the future. He said there have been significant delays for some time now within the healthcare system with “no improvement” shown in recent data.
This includes handover delays during the time Andy was unwell and he noted that data from earlier this year shows such delays have only gotten worse. All of which he said is due to “inadequecies” in social care and a lack of care in the community.
“Andrew died from an undiagnosed but treatable heart condition following an ambulance day contributable to a systemic failure related to the whole system of health and social care,” he concluded. “The ambulance delay was possibly a cause of death in that it denied Andrew potentially lifesaving treatment.”