Hour and a half wait on ambulance did not affect outcome of 38-year-old Sheffield nan who died, inquest finds
The death of a Sheffield woman who had just become a grandmother would not have been avoided had she been taken into A&E sooner, an inquest found.
Emma Ashley, aged 38, passed away in hospital from natural causes on October 27, 2023, after a Covid-19 infection triggered swelling of tissue in her airway.
Struggling to breathe, she called an ambulance at 1:52am on October 24, and joined a queue of 12 other ambulances at Sheffield’s Northern General A&E around 35 minutes later.
Daniel Douglas, the emergency medicine technician in the ambulance, said: “After the consultant examined her [in the ambulance], he was satisfied that she was okay to remain there and wait for space [in A&E].”
The three to four minute review by the doctor was “what was expected” and Mr Douglas said he did not believe the doctor had “cut a corner”, and she was stable at the time.
He added: “It was a short period of time between examination and deterioration. It was very out of the blue and there were no warning signs that it was coming."
Just past 4am, after being in the ambulance bay for around an hour and a half, Emma suffered a cardiac arrest and was taken into hospital where she suffered two more.
She was intubated but suffered a brain injury, and was deemed to be brain stem dead three days later.
Emma’s family, who had no legal representation at the hearing, expressed concerns about the wait time and lack of communication from the hospital.
Pauline Ashley, Emma’s mother, aged 74, said: “It was 9:38am - that time is etched in my brain forever - when I got a call from a doctor, who very casually said, ‘you know your daughter’s in hospital?’.
“That was the first I heard of it, and she’d been there all those hours. And it turned out she had three cardiac arrests, and I only thought she had one.”
Dr Benjamin Cooper, medical director at the emergency department, who was not present at the incident, admitted the hospital did not communicate effectively.
He added: “The wait outside in the ambulance was unacceptable, but a symptom of a struggling system that has been struggling for many years.
He told the coroner it was appropriate for Emma to stay where she was, adding: “The process of the disease wouldn't have changed had her location changed.”
Emma’s family said at the inquest at Sheffield Medico-Legal Centre on November 8 that they are trying to organise a further meeting with the hospital.
Pauline Ashley said: “She had just had her first grandchild. He was 18 months old when she passed away. She will never get to see him grow up.
“Not a day goes by that we don’t say to Jaxon, ‘where’s Nannie?’, and he will say, ‘Nannie up in the sky’.”
After the inquest, she added: “I could never understand why people kept ashes. I could never understand why you would want to, but I do now. I can’t let her go. I can’t have her going anywhere but with me.”
Ciaran Ashley, Emma’s only son, aged 20, said: “My mum was the best. We didn't always have the most money, but she did whatever she could to make sure we had a roof over our heads.
“She loved [her grandson] Jaxon to pieces. If she was ever feeling upset, she wanted to see him because of how much she loved him, it made her happy to see him.
“I just wanted everyone to know that my mum loves my son more than anything in the world.”
Dr Jennifer Hill, Chief Medical Officer, Sheffield Teaching Hospitals NHS Foundation Trust said: “Tragically, Emma died from a very rare complication which caused her epiglottis to swell and affected her ability to breathe.
“Emma was assessed by a consultant whilst in the ambulance and at that point in time was unwell but had remained in a stable condition.
“Although the coroner concluded ... her deterioration and death could not have been predicted or prevented, we remain very sorry that she had to spend time in an ambulance.
“Regrettably, there was also a delay in contacting Emma’s parents when she came to A&E due to our staff being so busy.
“We fully acknowledge that contact should have been made much sooner and for that we unreservedly apologise for the distress it caused them at such a devastating time. We have made changes since to limit the chances of it happening again.”