Man bleeds to death waiting over nine hours for ambulance after calling for help

A man who fell and cut a vein in his arm at home tragically bled to death after an took nine hours to respond to his call for help.

Peter Parker called 999 for an ambulance on September 10, 2021, at around 9pm, after he on broken glass. Mr Parker told the call handler that he had cut a vein and that blood was pumping out of his wrist. But just three minutes into the call, as the handler was instructing him on how to stem the bleeding, the call was disconnected.

The caller, from the Ambulance Service Trust, then attempted to reconnect the call five times and make welfare checks but were unsuccessful. The call was flagged as an Amber 1 priority, which meant it would be dealt with after red priority calls were cleared. But during this time, Mr Parker bled to .

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Aled Gruffydd has issued a prevention of future deaths report after he was found dead by emergency service crews on September 11, 2021. A rapid response vehicle arrived at Mr Parker's home at 6.30am and gained access to his home with the help of police at 7am. The coroner described this as "approximately nine and a half hours after the ambulance was requested." Mr Parker was declared dead at 7.09am.

The coroner described how the inquest found that ambulances were waiting at emergency departments to hand over patients, meaning they were not free to respond to other calls. Some ambulances were waiting 11 to 12 hours at the time to hand over. A system introduced in 2015 states that an amber call should be responded to within 20 minutes - with a person with a transected radial artery expected to survive for only 30 to 45 minutes.

Mr Gruffydd said in the report: "I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at , in accordance with the ambulance's duty of care, and therefore not responding to emergency calls as is their purpose."

The coroner gave a narrative conclusion following Mr Parker's death as a haemorrhage from a transected radial artery caused by a broken glass at home, and contributed to by the significant delay in the arrival of the requested ambulance. He added: "There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of nine hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes."

The report has been sent to the Welsh Ambulance Service, the Swansea Bay University Health Board and the Welsh Government. They are expected to respond to the report with action they will undertake to prevent future deaths within 56 days.

Lee Brooks, executive director of operations at the Welsh Ambulance Service, said: "We were deeply sorry to hear about the death of Mr Parker and I would like to extend our thoughts and condolences to his family and loved ones. We take coroners' recommendations very seriously and we will of course do all we can to respond to them."

"Pressures across the health and social care system are well-documented and the ambulance service is not immune to those pressures, which is why we are thinking about how we deliver ambulance services differently in the future. Currently, ambulance crews spend a large proportion of their time supporting patients outside emergency departments, which of course means that they are not able to attend other calls in the community."

"We're actively looking at what we can do to use the skills of our people differently, to manage patients closer to home and make our emergency ambulances more readily available for patients like Mr Parker. While it's never easy receiving a Prevention of Future Deaths report from coroners it's important that we reflect on how we can accelerate our improvements and also collaborate further with health and social care partners to help deliver meaningful and lasting change and provide patients the care that they deserve."