The death of a motorcyclist who had to wait almost an hour for a paramedic to attend the scene of a crash was contributed to by ambulance service neglect, a coroner has ruled.
Aaron Morris, a father-of-five, suffered a cardiac arrest in an ambulance which his wife Samantha was directing to hospital because the driver did not know the way, an inquest in Crook, Co Durham, was told.
Mr Morris, 31, died at the University Hospital of North Durham on July 1 2022 at 6.40pm, after a crash which happened about six hours earlier in Esh Winning.
His wife, pregnant with twins at the time, was returning from a hospital appointment when she came across the scene of the crash, in which her husband’s Honda motorbike collided with a car at a junction.
During the inquest, coroner Crispin Oliver was told that it took 54 minutes for an ambulance to get to the scene because of high demand.
It is highly likely that Aaron Morris would have survived had available specialist medical treatment been applied in a timely manner
The North East Ambulance Service target for arrival at the scene was 18 minutes.
Mr Oliver heard during the inquest that one expert rated Mr Morris’s chance of survival as high as 95%, had he been treated in a timely manner.
The coroner also heard that an air ambulance could have been sent to the scene earlier, but that did not happen.
Mr Oliver was also told that a specialist paramedic known as a clinical team leader (CTL) should have gone to the scene, but she did not leave a meeting being held in Stanley.
The coroner said: “It is highly likely that Aaron Morris would have survived had available specialist medical treatment been applied in a timely manner.
“That it was not was due to a) delayed allocation of an ambulance deployed to the scene due to overstretched resources and b) failure of the ambulance service CTL to deploy to the scene at 12.52, when there was certainly enough information for her to do so.”
Mr Oliver concluded: “Aaron Morris died from injuries sustained in a road traffic collision and failure of the response of the ambulance service, contributed to by neglect.”
A private ambulance, run by the firm Ambulanz, was first to get to the scene of the crash, the inquest heard.
Mr Morris died from chest injuries he sustained in the crash, after which he was conscious and breathing but in serious pain.
Mr Oliver said two experts found there was a tipping point before Mr Morris’s cardiac arrest in the ambulance, before which he would have probably survived had the correct medical intervention been available.
He had a cardiac arrest at 1.52pm, and one expert said the tipping point could have been as little as five to 10 minutes before it happened.
The coroner said witnesses from the institutions involved in the inquest had conducted themselves in a “humane” way at the hearings, and the organisations involved “showed themselves to be considerably chastened by their own review of the circumstances as to what happened”.
Outside the hearing, Mrs Morris said she welcomed the improvements made by the North East Ambulance Service and the Great North Air Ambulance Service (GNAAS).
She said: “The transparency and proactive approach of NEAS and GNAAS is appreciated and I am glad lessons have been learnt.
“Changes have already been implemented to prevent other families having to go through such a terrible experience.
“They have offered me support before, during and after the inquest and we have had open discussions about how the new trauma desk works and the organisation changes that have been made.
“After hearing the evidence from Dr Noble, medical director for NEAS, on preventing future deaths, I would now feel confident dialling 999 and requesting a North East Ambulance, which I never thought I would say.
“I do not doubt that, had GNAAS attended, the skills and expertise of their paramedics would have saved Aaron’s life.
“We are lucky to have such a charity in our region.”
She added: “For almost two and a half years, my focus has been on finding answers as to why Aaron died and this inquest.
“I have spent much of that time in hospital with my twin boys, who were born prematurely and who have received a lot of medical treatment since then.
“I want to now focus on my children and moving forwards.”
Laura Gabbey-Cristofini, specialist fatal accident solicitor at Irwin Mitchell, representing Mr Morris’s family, said: “The last couple of years and trying to come to terms with Aaron’s tragic death has been incredibly difficult for Samantha.
“Her pain has been compounded by the many unanswered questions and concerns she had regarding the events that unfolded.”
Dr Kat Noble, medical director for North East Ambulance Service, said: “Firstly, I would like to say to Samantha, and all of Aaron’s family, that I am deeply sorry.
“When concerns were raised with us about Aaron’s care we reported these as a serious incident and undertook a thorough investigation into what had happened.
“We shared the outcome of the serious investigation review with Aaron’s family.
“There were a number of organisations involved in this case and we unreservedly apologise for not providing the right care from our service when Aaron needed it.
“We accept that opportunities were missed to deploy a clinical team leader to this incident.
“This is the responsibility of the teams monitoring incoming and changing information about a patient’s condition, rather than one responder alone, and we have made changes to our deployment processes to ensure that this couldn’t happen again.
“There were a number of other actions arising from the review of this incident that we have taken forward to improve the co-ordination of our response and we fully accept the coroner’s findings and conclusion.”
