A dad who died in a motorbike collision just weeks after learning that his wife was expecting twins stood up to a 95% chance of survival of the injuries he suffered, an investigation has found.
Aaron Morris, 31, died following a collision in Esh Winning on July 1. An internal investigation by North East Ambulance Service (NEAS) revealed there was a "series of errors and system failures" which led to his death and have now apologised.
Today his wife Samantha spoke of the moment she read the report. The 28-year-old said: "Getting the report felt like the day he died all over again. You go numb and it's like the world is frozen around you.
Read more: Young widow gives birth to twins just months after husband died in tragic County Durham crash
"The difference this time round was I had the twins and they were screaming as I was being told all these failings that killed my husband and their dad."
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The investigation found that the ambulance should have arrived within 18 minutes but took 49 minutes 49 seconds to arrive on scene, along with a number of other failings.
The first call was made at 12.27 by the driver of the vehicle and there were ten 999 calls waiting in a queue at the time. It took 98 seconds for the call to be answered, however, the report states that the expected standard is that the call should be answered within five seconds.
At least six 999 calls were made requesting support for Aaron, including repeated calls from a police officer and an off-duty nurse advising that Aaron's condition was getting worse. The report states that at 12.55 a police officer requested an ambulance "on the hurry up", to which they were informed that due to 74 outstanding emergencies, the call was still awaiting allocation.
An Air Ambulance was also requested as Aaron's condition deteriorated. However, the call handler referred to earlier information that the Great North Air Ambulance Service (GNAAS) had already spoken to the off-duty nurse on scene and advised that they were currently not required.
The report added that the clinical update from the scene and request for the air ambulance was not documented in the call notes and was not passed to the air ambulance desk. An Air Ambulance was available if required.
Samantha said: "That's one of the biggest things that gets me. I understand that there wasn't many ambulances available, but knowing that an air ambulance was available and could have been on the scene if only they were aware that Aaron's condition was deteriorating.
"They could have saved his life if updates had been fed back to the air desk and that's one of the toughest things to take from the report."
When one ambulance from a third party company, staffed with a paramedic and an Emergency Care Assistant (ECA) arrived at the scene at 13.21, crew documented that Aaron's breathing was abnormal, he had a weak pulse, and a temperature of 36, but was cold and pale to touch.
They were en route to the closest major trauma centre at Newcastle's Royal Victoria Infirmary when Aaron went into cardiac arrest and crews redirected to University Hospital of North Durham.
But the ECA was "not familiar with the area" and could not operate the sat-nav system. Samantha then had to direct the crew to the hospital.
Samantha said: "It was absolutely horrific. I'm stuck in the front of an ambulance trying to direct it to the nearest hospital when all I can hear is Aaron being given CPR and chest compressions being given.
"All I could hear was Aaron's chest being jumped on while I'm trying to direct this driver and all I wanted to do was get in the back of the ambulance to be with Aaron. The last thing he said before he went into cardiac arrest was 'where's my wife at?'
"The paramedic said 'she's just in the front mate' and then he started saying 'Aaron, Aaron' and then he shouted 'trauma arrest, trauma arrest. Divert, divert'. He must have known he was going and wanted to know where I was and I just couldn't get to him until they slightly revived him at Durham.
"I was trapped in the front of this ambulance and he was dying in the back. It kills me thinking about it. It traumatises me and to this day I still think about it every day."
Aaron didn't arrive at Durham hospital until 14.14, almost three hours after the original 999 call was made. Aaron died from his injuries after arriving at the hospital with his wife by his side.
Samantha added: "Our life was just starting when Aaron passed away and my life is so different now that he's gone. I've got these two babies that have never met their dad. My past, present and future was taken away when Aaron died."
Despite the findings of the investigation, Samantha remains grateful for the help of those who worked to save Aaron's life that day, particularly staff at Durham Hospital who treated Aaron and cared for his twins, Aaron-Junior John Robson Morris and Ambrose-Ayren Morris, when they were born in October, three months premature.
Chief operating officer at North East Ambulance Service, Stephen Segasby, said: "Firstly, I would like to offer our sincere and heartfelt condolences to Aaron's loved ones. This was a tragic event.
"When concerns were raised with us about Aaron's treatment we reported these as a serious incident and began an internal investigation into what had happened. We have now shared the outcome of the serious incident review with Aaron's family.
"There were a number of organisations involved in this case and we unreservedly apologise for not providing the response from our service that Aaron should have received. There are a number of actions arising from the review of this incident that we are committed to taking forward to improve the coordination of our response.
"We will of course now cooperate fully with the coroner to provide all the information required to make their independent judgement and for that reason it would not be appropriate for us to comment further on the detail of this case until that process is concluded."
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