A 72-year-old grandma died after waiting all night for an ambulance despite being categorised as high priority, an inquest heard.

A coroner has raised concerns over a risk of ‘future deaths’ at an ambulance service after Susan Dear, from Berkshire, was left unattended for seven hours after her family first called 999.

Coroner Hannah Godfrey has now written a ‘Prevention of Future Deaths’ report to NHS England over concerns regarding South Central Ambulance Service’s response times.

Mrs Dear’s family had called for emergency care at 10.20pm on January 3, 2023, after she began to suffer from abdominal pain. The 999 call was triaged at category 3 – meaning that an ambulance was expected to be on scene within 120 minutes.

But the inquest heard that at the time there was a backlog of 48 patients awaiting ambulances, seven of which were waiting for category 2 ambulances with the longest wait time being 1 hour 12 minutes, and 19 patients were waiting for category 3 ambulances with the longest wait time being 7 hour 55 minutes.

As Mrs Dear’s condition deteriorated, her family made a second call to 999 in the hopes an ambulance would attend their Berkshire property promptly.

The call, made at 2.32am on January 4, was now triaged at category 2, making it a higher priority, with an ambulance expected to be on scene within 40 minutes.

At this time, there were 37 patients waiting for ambulances. nine patients were awaiting category 2 ambulances with the longest wait being 5 hours 53 minutes, and 26 patients were awaiting Category 3 ambulances, with the longest waiting time being 14 hours 39 minutes.

Despite waiting another two and a half hours as Mrs Dear’s condition worsened, no ambulances were able to respond to her.

At around 5am, her family decided they could wait no longer and drove her to the hospital, where she was confirmed dead at 6.02am.

The coroner’s conclusion does not find that the ambulance delays contributed to Mrs Dear’s death, but put the death down to natural causes – pulmonary embolism due to underlying deep vein thrombosis.

However, the coroner felt the evidence raised at the hearing raised concerns over risks that future deaths could occur unless action is taken.

When the second 999 call was made on behalf of Mrs Dear, the area was in Operational Pressures Escalation Levels (Opel) four.

This indicates ‘extreme pressure’ on resources.

An internal investigation by the ambulance service found that there had been ‘no missed opportunity’ to send an ambulance during the time that Mrs Dear was waiting for one, due to the fact there were none that were available.

The report, recommending action be taken to ‘prevent future deaths’, found that on the night of January 3-4, ‘patient’s lives were put at risk because SCAS did not have ambulances available to meet the level of demand resulting in severe delay and ambulance response times far outside the national expected standards’.

However, the coroner found that this was not an isolated or ‘unprecedented’ issue, but ‘was reflective of a picture of a chronic situation whereby there was a continuing risk that demand for emergency ambulances would outᵴtriƥ resources and SCAS were unable to reassure me this was a situation that had been resolved’.

The inquest into Mrs Dear’s death took place from May 23 this year and concluded on September 9.

The report also looked at the ‘chronic understaffing’ of the service nationally, and pointed towards handover delays at Royal Berkshire Hospital and the Wexham Park Hospital, which then held up ambulances from responding to calls.

It reads: ‘SCAS’s service was operating at under the number of planned staff for that night, (despite the service taking all reasonable steps to meet requirements) due to chronic understaffing of the service with recruitment and retention issues with paramedic and other emergency response staff that the inquest heard are problems nationally.

‘Handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available).

‘This was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community.’

The coroner also found that resources were being ‘wasted’ due to the ‘ignorance’ of some members of the public who call 999 or opt for emergency care when it is not appropriate, putting a further strain on the NHS.

A response from NHS England to the coroner’s report expressed ‘deep condolences’ to Mrs Dear’s family, and recognised the ‘significant pressures on all NHS services, including ambulances’, stating that it was prioritising improvements to Category 2 response times.

Their response read: ‘Despite significant challenges, including unprecedented industrial action and higher than anticipated demand, there has been a marked improvement in 2023/24, with over 2.5 million more people completing their A&E treatment within 4 hours compared to 2022/23.

‘Work has also focused on the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow.

‘My regional colleagues in the South East have engaged with SCAS on the concerns raised in your Report. There are number of local initiatives and improvement programmes underway to improve their performance and ensure that the Trust is delivering the best care to its patients. They advise that they are on target to employ an additional 100 paramedics this year, through an international recruitment programme, and that they have purchased additional ambulances through the national procurement framework.’

Mark Ainsworth, director of operations at South Central Ambulance Service, also expressed the service’s ‘sincere condolences to Mrs Dear’s family and loved ones’.

He explained: ‘At the time of her emergency call in January 2023, and as noted by the Coroner in her report, there wasn’t an opportunity to send an ambulance to Mrs Dear earlier due to the fact that demand for our emergency service outᵴtriƥped the available resources at that time, with a significant number of ambulance crews delayed at the Royal Berkshire and Wexham Park Hospitals waiting to handover patients.

‘Since January 2023, the trust has embarked upon a number of improvement programmes including recruiting more paramedics, upgrading the ambulance fleet and implementing a number of operational efficiencies with our hospital partners, such as undertaking immediate handovers at hospital once certain, agreed demand or pressure trigger points are met.

‘Shortly, we will also be implementing a trust-wide release to respond policy that ensures ambulance crews are not delayed by more than 45 minutes once they arrive at hospital with a patient.

‘With demand across the NHS now recognised to be at unprecedented levels, the trust continues to work with its health partners to minimise the impact of hospital handover delays on our ability to respond to patients in the community and the executive management team is fully focused on delivering all aspects of the trust’s operational modernisation and transformation programme.

‘This programme will see a range of connected projects delivered from 2024-29 to ensure that the trust can provide high quality care, achieve performance standards and support staff wellbeing, whilst operating within its allocated budget.’