Bridport man died after waiting eight hours for an ambulance

Kenneth Michael Adams died on October 19 2021 hours after suffering a scalp injury at his flat.

In a Prevention of Future Deaths Report, Dorset Coroner Brendan Allen said that the algorithm used by the ambulance service dispatch system did not register the bleeding as a "serious haemorrhage" which delayed the response.

He highlighted that due to the medication Mr Adams had been taking there was 'a considerable risk that the bleeding would persist until the wound was closed' and left him at risk of hypovolaemic shock.

South Western Ambulance Service has apologised.

The coroner heard how at around 3.30am, Mr Adams, who lived alone at Vernons Court in Bridport - supported housing provided by a housing association - suffered an accidental fall from a standing height, which resulted in a laceration to his scalp.

Mr Adams had been prescribed clopidogrel - an antiplatelet medication which helps prevent blood clots.

At 4.06am Mr Adams contacted the ambulance service to explain that he had fallen, injured his scalp and that he could not stop the bleeding.

Mr Adams’ call was classed as a category 3 ambulance response. The national target set by the Department of Health is to respond to these incidents within 120 minutes (by 6.13am).

At the time of the call, Mr Adams reportedly appeared well with no additional symptoms.

Four hours after the fall, at 7.53am, he reported to a careline operator that he was now feeling sick, that he was wobbly when stood up and that his bleeding was continuing.

The report from the coroner said: "The algorithm being used failed to account for the persistent nature of the bleeding being experienced and that Mr Adams was prescribed clopidogrel."

At 10.25am when Mr Adams again spoke to a careline operator, he was by now slurring his words and his speech was noticeably slow.

It is likely he was experiencing symptoms associated with hypovolaemic shock.

Mr Allen said: "If Mr Adams had received treatment by 10.25am, he would have survived the injury he had sustained."

The first ambulance arrived at Mr Adams’ property at 11.56am, by which time a neighbour had found Mr Adams.

Mr Adams was taken to Dorset County Hospital, where despite treatment he died that day.

The coroner said the prioritisation was not raised from category three because the wound was not "spurting or pouring blood".

The algorithm also did not consider medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleeding.

An inquest concluded that Mr Adams died as a consequence of an accident which was "more than minimally contributed" by a "failure to provide emergency medical assistance in a timely manner".

It added: "A failure of the Medical Priority Despatch System to acknowledge and assess persistent bleeding from a scalp injury against a background of anti-platelet medication also possibly contributed to his death."

The report was addressed to the algorithm creator, International Academies of Emergency Dispatch (IAED) and the coroner said: "In my opinion, urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action."

A spokesperson for care line operator Appello said: "Our initial findings indicate that all procedures relating to calls at the property were followed appropriately."

In a statement, a spokesperson from South Western Ambulance Service said: "We are sorry that we were unable to provide a timely response to Mr Adams and we would again like to offer our sincere condolences to his family and loved ones.

"Our ambulance clinicians strive every day to give their best to patients, but our performance in 2021 had not returned to pre-pandemic levels, after a prolonged period of increased activity levels.

"Health and social care services remain under enormous pressure. We are working with our partners in the NHS and social care, to do all we can to improve the service that patients receive."