Prevention of future deaths report: Bobilya Mulonge (14 May 2024)

Summary

On 24 May 2023 an investigation was commenced into the death of Bobilya Mulonge then aged 62 years. The investigation concluded at the end of the inquest on 19 April 2024. The conclusion of the inquest was a narrative conclusion that Mrs Mulonge died as a result of congestive cardiac failure against a background of hypertensive heart disease. Ambulance response times probably contributed to her death.    

The medical cause of death being:  

• 1 (a) Congestive Cardiac Failure
• (b) Hypertensive Heart Disease  
• II) Chronic Kidney disease and Type II diabetes mellitus.

Content

Mrs Mulonge had multiple co-morbidities including hypertension with a history of hypertensive crisis, stroke, diabetes and she had multiple hospital admissions in 2022. On 24 November 2022 at 06:09 an ambulance was called because her breathing was laboured, and her consciousness was reducing. During the call she became unconscious. When an ambulance arrived 72 minutes later, at 07:24, she was in cardiac arrest. Her heart was restarted but despite appropriate treatment she continued to deteriorate and died at 10:45 on 24 November 2022 at Tameside General Hospital, as a result of congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus.

The Inquest heard that the North West Ambulance Service was unable to meet average response standards at the time of the 999 call mainly due to the fact that ambulances were unable to clear the region’s hospitals because of the long waiting times there. In addition, there were high call volumes. A level 4 incident plan was commenced as a result.

Matters of concern

Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments.

Measures undertaken by the North West Ambulance Service

A number of measures have been undertaken by the North West Ambulance Service to address emergency response times including:

• Regular meetings take place between the North West Ambulance Service and NHS Trusts in the region to discuss the delays at a regional level.
• There are faster communications between senior leaders in the North West Ambulance Service and NHS Trusts when there is a period of high demand or delay.
• North West Ambulance Service managers are deployed to struggling Accident and Emergency departments.
• A delayed handover checklist is in place.
• Patients are triaged to assess if they can wait in a waiting room to release ambulances – this is called Fit to Sit.
• Patients who can be safely grouped with other patients and looked after by one ambulance crew rather than in individual ambulances are placed together to release ambulances.
• The North West Ambulance Service now has an option to remove crews with 15 minutes notice to the hospital.
• Batch Divert is in place which allows the North West Ambulance Service to send an ambulance to another hospital.

The inquest heard that waiting times across the North West region are still impacted by problems clearing the regions hospitals despite the above measures.