An inquest has heard how Andry Waters could possibly have been saved if it weren’t for NHS failings (Image: Getty Images)
Nicola Waters, a resident of Indian Queens in Cornwall, has expressed her ‘disgust’ at the decision to send a taxi instead of an ambulance for her husband who suffered a fatal heart attack.
In the early hours of May 24, 2024, Nicola dialed 999 at 2.37am when her husband, Andrew ‘Andy’ Waters, 56, experienced severe chest pains accompanied by trembling and vomiting. Tragically, Andy passed away after being taken to Royal Cornwall Hospital.
An inquest held on March 13 revealed that Andy’s death might have been prevented if not for the delay in ambulance services, which was attributed to « systematic » issues within the NHS. The three-hour hearing at Cornwall’s Coroners Court in Truro detailed how Andy, normally fit and healthy, endured excruciating pain on the night of May 23.
In the days prior, he had brushed off escalating chest pains as mere indigestion, according to CornwallLive. His condition deteriorated until his wife urgently contacted emergency services, reporting his chest pain, arm numbness, sickness, and shaking.
The call was classified as a Category 2 by the South Western Ambulance Service NHS Foundation Trust (SWASFT), indicating high severity.
The gravest situation under the emergency categories is Category 1, designated for incidents involving life-threatening and immediate medical attention, which was not initially assigned to Andy’s case. Mrs Waters stressed during her call that the issue must be urgent given Andy’s lack of any prior complaints regarding illness or pain, conveying her suspicion that it could be a heart-related problem.
When the distress intensified, she called again, reporting that « the pain was becoming unbearable ». Despite this escalation, she was informed that Andy remained on the waitlist and that an ambulance would arrive as urgently as possible.
At this stage, Andy was suffering deeply, « writhing » in agony on the floor, with symptoms including vomiting and persistent tingling sensations. Mrs Waters received advice to fetch a defibrillator from a nearby garage, only to discover upon arrival that she needed a code which she had not been provided, and without her phone, she was unable to take the device.
By the time she got back to Andy, his condition had further declined, leaving her unable to leave his side to seek further aid. Tragically, a navigation assistant from SWASFT reached out to Mrs Waters two hours after her first call but failed to initiate a clinical assessment to determine whether Andy’s situation had escalated and if the urgency category warranted an upgrade.
A taxi was called at the early hour of 4.40am by the ambulance service to transport a patient in an emergency, but the driver was unaware of the critical nature of the situation and was visibly upset upon learning this upon arrival. Andy reached the hospital at 5.37am, three hours after the initial call for help, and immediately suffered a heart attack.
The medical team sprang into action, performing emergency heart surgery in a desperate bid to save his life.
Tragically, despite their efforts, Andy could not be saved. Mrs Waters, while grieving, expressed no criticism towards the medical staff once they were involved.
« Andy was so healthy and he was never ill and I think he deserved so much better from our health services, » she lamented in her statement addressing the delay.
Her frustration was palpable as she continued: « I am angry, I am sad and I don’t believe this should have happened. To have been sent a taxi is disgusting. »
Instead of an ambulance, a taxi was dispatched to the emergency call (Image: Getty Images)
The subsequent investigation by coroner Guy Davies revealed a grim picture: seven ambulances were queued outside the hospital at the time Andy needed to be admitted.
The hospital itself was grappling with severe systemic issues, as 84 patients who were medically fit to leave remained admitted due to the widespread crisis of bed blocking and community care challenges. This bottleneck, caused by the scarcity of care packages and care home spaces, leads to ambulances being stuck in queues, patients in tow, waiting for beds to free up.
Paul Graham, an investigations officer with SWASFT, shed light on the challenges faced by ambulance services at the time of Andy’s 999 call. According to Mr Graham, there were « major delays » at local hospitals and this contributed to the service being under strain from 18 other Category 2 patients also in need of assistance.
Mr Graham acknowledged shortcomings in the response, noting a missed opportunity for additional clinical triage which could have potentially escalated Andy’s case to a between-category status, giving him precedence in the waitlist.
At the inquest, Mrs Waters delivered an emotional testimony, expressing her profound grief and frustration. She declared to those gathered, « my husband is not a number », criticising the inadequate response that culminated in a mere taxi transport to the hospital, long after their emergency plea.
Mrs Waters poignantly revealed the toll her husband’s loss has taken on her life: « 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 extended an apology to Mrs Waters on behalf of SWASFT, acknowledging that an ambulance should have been dispatched. He attributed the failure to a broader systemic issue within the NHS.
He reassured her that she was not at fault and praised her calmness and efforts during the distressing situation.
He also revealed that the call handler who made a mistake during Mrs Waters’ third call – failing to transfer it to a clinician for assessment – is no longer employed by SWASFT, though he did not elaborate on the reasons.
« [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 identified a « systemic failure » in health and social care as the cause of ambulance delays and, consequently, Andy’s death. He suggested that available procedures could likely have saved Andy’s life, but the cardiac arrest upon hospital arrival and the delay in reaching there « massively diminished » his survival chances.
He plans to issue a Prevention of Future Deaths report due to the risk of more fatalities. He noted that significant delays have persisted in the healthcare system for some time, with « no improvement » evident 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.
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