Inquest into death of Sheffield driving instructor who dialled 999 but then cancelled ambulance and passed away
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Ronald Ward, of Firth Park, had complained of severe stomach pain on October 13, 2021 and passed away two days later at Northern General Hospital due to cardiac arrest.
An inquest held at Sheffield Coroner's Court on Monday, July 11 heard that Ronald, who had a pacemaker fitted, had dialled 999 at 7.11am on October 13 due to stomach pain, vomiting and shortness of breath.
Paramedics then arrived at 7.55am, advice was given and he was offered to be taken to the hospital for further checks but he declined as he was 'feeling a lot better'.
He then made another emergency call later that day at 3.50pm and complained of 'sharp pains' in his stomach and that he was having 'bitter constipation', only to cancel the ambulance service at 4.38pm.
However, at 5.50am on October 15, Mr Ward called for an ambulance again, complaining of a swollen stomach and difficulty breathing and he was taken to hospital, where he died of cardiac arrest.
Dr Caroline Kendrick, an emergency department consultant at the Northern General Hospital told the inquest that Mr Ward as 'very pale, very sweaty' upon his admission and that he had a low blood pressure.
She also said that there wasn't any point that Mr Ward had complained of a chest pain and that he went for a CT scan for his abdomen which showed that there was a fluid in his gallbladder and lower lungs.
And at approximately at 1pm, Dr Kendrick said Mr Ward suddenly deteriorated and his oxygen levels dropped.
She said: “His heart rate went fast and unfortunately we lost a pulse. And at that point, he was deemed to be what we call cardiac arrest.”
Asked if it would have made any difference of the outcome if he had attended hospital two days earlier, she said: “There are a lot of variables and a lot of possibilities. I can only personally comment on the way I saw Mr Ward on the morning that I saw him and at that point, he was acutely unwell.
“It's very difficult to answer if I'd seen Mr Ward two days earlier because I've been in situations where patients can look very well when they arrive and deteriorate very quickly.”
‘Very surprising' outcome
Mr Neil Balls, the paramedic who attended Mr Ward on the morning of October 13 admitted that he should have spoken with his GP before leaving his home.
He said: “I think it's very surprising that it was a cardiac event, considering his symptoms were abdominal pain on the day I was there.
“I think I could have done differently with the way he was presenting, I should have spoken to the GP myself before leaving the premises rather than Mr Ward doing it himself.”
Jonathan Mills, a Yorkshire Ambulance Service paramedic, said it was difficult for phone handlers to advise patients when they change their minds about using the ambulance service.
He said: “It's difficult to do that over the phone without the patient's parameters...this is the first time I've ever had or been involved in an instant where a patient has called to cancel and then subsequently got on to deteriorate in a significant way that I've been aware of.”
He said following the event, he and other staff had been on a clinical refresher course to look at bias in diagnosing patients, considering that Mr Ward's diagnosis was focused on his constipation.
Assistant Coroner Ms Tanyka Rawden then returned with a verdict that Mr Ward had died of natural causes but found 'a missed opportunity' on the part of Yorkshire Ambulance Service.
However, she stressed that it would not have known that the death would have been prevented had the consultation occurred or had he been taken to the hospital two days earlier.
She said: "What I found is that there was a missed opportunity that the paramedic crew should have contacted his GP to talk about constipation and also to look at any other possible diagnoses.”
‘My father was very passionate about his beliefs’
She then expressed his sincere condolences to Mr Ward's wife of 52 years, Linda and their son, Steven who were present at the inquest.
In a tribute, Steven said: “Like any adult 40 to 50 years ago who worked in the steelworks, he started to become a shop steward.
“He believed in people and did the best thing for people. So from being a shop steward he rose through the ranks to become a deputy convener and then convener of Forgemasters where he looked after the workers rights of over 2,000 people at the time.
“My father was very passionate about his beliefs and getting the best for everybody. That's what he did all his life. He tried to get the best for everybody.”
He became a driving instructor after he took redundancy.