North East Ambulance Service failings and neglect contributed to death of dad of five Aaron Morris inquest rules

Failings from the ambulance service contributed to the death of a dad-of-five who died following a collision, an inquest has ruled.

Aaron Morris was due to become a dad to twins when he was involved in a motorbike collision and died on his wife Samantha's 28th birthday. Today, an inquest concluded that it was "highly likely" that the 31-year-old would have survived had "available specialist medical treatment been applied in a timely manner." The coroner ruled that there were elements of neglect from North East Ambulance Service (NEAS) in Aaron's death.

Aaron was waiting to meet his wife, who was 13 weeks pregnant, when his motorbike was involved in a collision with a car shortly before 12.27pm on July 1, 2022, at the junction with Priestburn Close and Newhouse Road, in Esh Winning, County Durham.

His wife was one of the first people at the scene as she made her way home from an overnight hospital stay to meet Aaron and prepare for a holiday in the Lake District, which they had planned that day.

Earlier this week, an inquest heard that trainee nurse Samantha had to run to a GP surgery to get medical supplies to treat her husband who lay in the road for almost an hour after the collision with leg and chest injuries, due to the 54 minute wait for an ambulance to arrive by his side. It should have arrived in 18 minutes.

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The first 999 call requesting paramedics to the scene was also delayed as a call which should have been answered in five seconds was on hold for 96 seconds.

Today, County Durham and Darlington Senior Assistant Coroner, Crispin Oliver, said that "delayed allocation of an ambulance to deploy to the scene due to overstretched resources" likely contributed to Aaron's death due to not receiving treatment on time.

Aaron died at the University Hospital of North Durham (UHND) at 6.40pm that day. He suffered a cardiac arrest in the ambulance, which departed the scene to Newcastle's Royal Victoria Infirmary (RVI) at 1:47pm and was diverted to UHND at 1.53pm. The ambulance crew were not familiar with the area and relied on directions from Samantha to find the nearest hospital when they had to divert, the inquest heard this week.

The Coroner today concluded that there would have been a "tipping point" in Aaron's condition before he suffered a cardiac arrest at 1.52pm, before which he probably would have survived with specialist support of an air ambulance. He told the court that the "tipping point" in Aaron's condition would likely have been between 1.42pm and 1.47pm, after which he probably wouldn't have survived.

He added that if the 999 call had been picked up and responded to within its target time then a paramedic or air ambulance should have arrived on scene by 12.45pm, providing a greater chance of survival.

The Coroner also ruled that "failure of [the] ambulance service's Clinical Team Leader to deploy to the scene from 12.52pm, when there was certainly enough information for her to do so", was another a failure which could have led to Aaron's death. During the five day inquest, the court heard that a Clinical Team Leader (CTL), was based approximately 9.1 miles away in Stanley at the time of the collision and could have attended.

However, the CTL was in a meeting she didn't need to be in and did not dispatch to the scene when a colleague queried whether she was available. She was the only operating CTL at the time of the collision, an inquest heard, and could have requested the support of an air ambulance. The CTL was a new role within the Trust at the time.

The Coroner concluded that "Aaron Morris died from injuries sustained in a road traffic collision and failures in the response of the ambulance service, contributed to by neglect."

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 coordination of our response and we fully accept the coroner’s findings and conclusion."

Following the five-day inquest, the Coroner thanked the organisations required to give evidence for their "highly instructive" and "responsible" approach. He added: "The response to what happened here has been a model of how institution interested persons in inquests should respond to a situation like this."

A spokesperson for Ambulnz, the third-party ambulance company which attended the scene, said: "From the outset we have taken the view that there are lessons to be learned for all of the emergency services involved in this sad case.

"The concerns that we as an organisation identified and actioned have been found by the Coroner not to have caused or contributed to Mr Morris' death, however we remain deeply saddened by the tragic circumstances of his loss. We send our sincere condolences to Mr Morris' family and friends."

A spokesperson for the Great North Air Ambulance Service (GNAAS) said: "Our thoughts are with all those affected by this tragic event, we offer our sincere and heartfelt condolences to Aaron's family and friends, and we are thankful his family now have answers.

"On this occasion, the injuries reported did not meet our dispatch criteria nor were we requested to attend; therefore the response efforts were managed by other emergency services. We will consider the findings of the inquest and review our processes to ensure we provide the best possible service.

"We remain committed to supporting our partners in emergency response, and continue to be on standby, ready to assist whenever our critical care services are required to provide urgent care to those in need."

Legal representatives on behalf of Barry Chappel, the driver of the car involved in the collision, said: "Sincere condolences are reiterated to Samantha Morris and family."

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