The ambulance failures that contributed to father-of-five’s loss of life: Biker’s accidents have been survivable however paramedic was in pointless assembly as he lay dying, operators took too lengthy to reply 999 name and driver acquired misplaced on option to hospital
A coroner today blamed ‘neglect’ by the ambulance service and ‘systemic failures’ for contributing to the death of a father-of-five following a road accident.
Aaron Morris, 31, died after it took 54 minutes for an ambulance to reach the scene of the crash and an hour and three-quarters before he arrived at hospital.
By then the chance to save him was lost.
The injured motorcyclist suffered a cardiac arrest in the ambulance and his pregnant wife had to give directions to the nearest trauma centre because the driver didn’t know the way, an inquest heard.
A crucial mistake was not sending a specialist medical team to the crash scene by air ambulance, the inquest at Crook in County Durham was told.
Coroner Crispin Oliver ruled it was ‘highly likely that Aaron Morris would have survived’ had specialist medical treatment been given ‘in a timely manner.’
He ruled this was due to the delay in sending an ambulance as a result of ‘overstretched resources’ and the failure of the Clinical Team Leader, who was in a non-essential meeting, to go to the scene.
Had she gone promptly an air ambulance could have been sent in time to save Mr Morris, the inquest heard.
Aaron Morris died at University Hospital North Durham at 6.40pm on July 1, 2022, hours after crashing with a car on the junction of Priestburn Close and Newhouse Road in Esh Winning, County Durham
Aaron suffered a cardiac arrest and died at University Hospital North Durham despite having a 95 percent chance of survival (Pictured: Aaron with his wife Samantha)
In a narrative verdict Mr Oliver found that Mr Morris died from chest injuries suffered in the road accident and the ‘failure in response by the ambulance service, contributed to by neglect.’
Mrs Morris, who was 13 weeks pregnant with twins at the time, listened intently as the Coroner detailed his findings – placing blame firmly with ambulance failures.
Her husband died on her birthday, 1 July 2022. She was on her way to meet him when she came across here husband lying on the road in Esh Winning, County Durham, near their home.
The inquest was told his motorbike collided with a car in good road conditions, but a lamp post may have obscured the car driver’s view.
The motorist Barry Chappell called 999 at 12.27pm and it took 98 seconds for the call to be answered rather than the target five.
An ambulance should have been at the scene within 18 minutes but it took 54 minutes for a third party company ambulance to reach him.
By then there had already been a missed opportunity to send the regional air ambulance.
A nurse practitioner at the scene had spoken to the air ambulance service at 12.58pm but insufficient information was obtained to make the correct call, the inquest heard.
Aaron’s wife Samantha Morris was 13 weeks pregnant with her twin boys Aaron-Junior John Robson Morris (left) and Ambrose-Ayren Morris (right) at the time of the tragedy
The inquest was told Aaron’s motorbike collided with a car in good road conditions, but a lamp post may have obscured the car driver’s view
Samantha was celebrating her birthday and had set out to meet her husband when she found him lying in the road
Mr Oliver said there was a ‘tipping point’ after which treatment would not have saved Mr Morris and he put that at between 1.42pm and 1.47pm, well over an hour after the 999 call.
The coroner said the long delay in the ambulance arriving was a ‘resources derived failure of the system’ rather than simple human error.
However, he found there was ‘legal neglect’ from the failure of clinical team leader Sarah Hall to leave a meeting nine miles away to go to the scene of the accident.
Had she arrived promptly she could have ordered the air ambulance, the coroner said.
The specialist team ‘would probably have arrived in time to provide life-saving treatment,’ he said. ‘I am quite satisfied this constitutes neglect.’
Mr Morris was pronounced dead at the University Hospital in North Durham at 6.40pm that day.
At the end of the hearing Mr Oliver thanked Mrs Morris and her family. Addressing the widow, he said: ‘It’s done. I hope to some extent you can get your life back together again.’
He also praised the organisations, including the North East Ambulance Service for the way they had addressed ‘systemic failures’ in a ‘constructive and responsible’ way.
Samantha, pictured outside court today, had to direct the ambulance driver to the hospital herself
After the inquest Mrs Morris revealed the added personal turmoil she has endured in caring for her twin babies who were born prematurely.
She said: ‘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 received a lot of medical treatment since then.
‘I want to now focus on my children and moving forwards. I hope that now the inquest has concluded I will have some closure, and I hope I can finally have the time to grieve.’
She said it had been a ‘difficult, emotional and exhausting week’, listening ‘to excuses and arguing over the minutes leading to Aaron’s death.’
But she said she was ‘glad lessons had been learned.’
‘Changes have already been implemented to prevent other families having to go through such a terrible experience,’ she said.
Mrs Morris added that she would ‘now feel confident’ ringing 999 ‘which I never thought I would say.’
She added that it was ‘in black and white that Aaron is not here because services didn’t do what they’re supposed to.’
She criticised the ambulance provider Ambulnz for failing to meet and discuss the case with her, describing it as ‘uncompassionate’ and ‘defensive.’
The former student nurse said of Ambulnz: ‘All they were bothered about in that inquest wasn’t about making changes and finding out what happened, it was about protecting themselves.’
By contrast she said the NEAS had been ‘compassionate and proactive.’
Adding: ‘Nothing anybody does is going to bring Aaron back. Me being resentful and full of hate isn’t going to make a change.’
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.’
