Andrew Waters, 56, from Cornwall could ‘possibly’ have been saved after he died from a heart attack if wasn’t for ambulance delays caused by ‘systematic’ NHS issues
The grieving wife of a man who died following a heart attack said she was ‘disgusted’ that a taxi was sent to take her dying husband to hospital.
Nicola Waters, from Indian Queens in Cornwall, initially called 999 for an ambulance at 2.37am on May 24, 2024 after Andrew ‘Andy’ Waters, 56, began trembling and throwing up with severe chest pains. He sadly died after being admitted to Royal Cornwall Hospital.
Despite the best efforts of all those involved in his emergency care upon arrival, an inquest on March 13 found that if it weren’t for the ambulance delay caused by “systematic” and nationwide NHS problems, he may still be alive and with his family. During a three-hour hearing at Cornwall’s Coroners Court in Truro, it was explained that Andy, who was an otherwise fit and healthy man, was in agonising pain on the evening of May 23.
For days leading up to this, he had dismissed the worsening chest pains as indigestion, reports CornwallLive. His wife eventually called 999 in the early hours of the morning to say that her husband had pain in his chest, numbness in his arms, sickness and was 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.
After being told to call back if things worsened, she did and told them that “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 the hospital at 5.37am (three hours after the first call) he suffered a heart attack and the medical staff jumped into quick action in an attempt to save his life, including performing emergency heart surgery.
They 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 concerning the delay.
She added: “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 the hospital waiting to offload patients at the time of Andy’s admission.
In addition, 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 – a lack of care packages and care home placements for such patients results 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 apologised to Mrs Waters 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 wife’s third call – 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,” Mr Graham 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. He 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. 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 “inadequacies” 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,” he added.
