Retired army Colonel died after wait in ambulance outside Treliske
The coroner says he'll be writing to the Health Secretary over concerns about delays
A former senior Army officer died after waiting more than four hours in the back of an ambulance stuck outside a busy hospital because there was no bed for him, an inquest has heard.
Colonel John Codd, 88, died in Royal Cornwall Hospital in Truro on January 16 this year after suffering a fall earlier that day.
Mr Codd, who was known as Bill, had fallen as he got out a taxi which was returning him to a nursing home in St Austell where he was receiving respite care.
Cornwall Coroner's Court heard Col Codd, from St Austell, had fallen onto the ground outside the home at 12.30pm and staff called for an ambulance.
The ambulance reached Col Codd at 2.49pm - two hours and 14 minutes after first being categorised as needing a response within an hour - as he lay on the ground covered in blankets.
Col Codd arrived at the Royal Cornwall Hospital in Truro at 4.30pm but was not admitted until 9.11pm because no bed was available inside - despite an ambulance handover target of just 15 minutes.
As he waited inside the ambulance, he was brought into the hospital to be triaged by a nurse at 5.47pm and then examined by a consultant at 6.10pm.
An x-ray was taken for a suspected fractured hip and at 8pm Col Codd was reviewed by a junior doctor, who then ordered a CT scan of his pelvic area.
At 9.11pm, Col Codd was finally admitted to the hospital and placed in the "majors" area of the department.
An hour later he was found on the floor with breathing difficulties having suffered a cardiac arrest from which he could not be resuscitated.
A post-mortem examination found Col Codd had suffered a fracture to the cup of his right femur and had developed a rare rectus sheath hematoma from the earlier fall, which was the cause of his death.
He had pre-existing atrial fibrillation - an irregular heartbeat - and changes in his blood pressure noted during medical reviews by doctors in the emergency department were attributed to this rather than the hematoma.
A report into Col Codd's death by the South West Ambulance Service NHS Foundation Trust said delays in reaching him were due to the hold-ups in handing over patients at hospital.
Emergency department consultant Dr Aaron Green said those delays were an ongoing problem.
"It has been an ongoing problem in many departments across the country, particularly in Cornwall, for many years," he told the inquest.
The inquest heard that for the six months to January, delays in admitting patients to a ward or sending them home totalled 24,000 hours at the hospital - the equivalent of shutting 32 emergency department cubicles for a whole month.
Andrew Cox, the senior Cornwall Coroner, said he had previously raised concerns with the hospital and ambulance trusts about handover delays.
"The problem is the ambulances in the wrong place at the wrong time - they are parked outside the emergency department at Truro who can't then respond to a call," he said.
The coroner said there were also delays in discharging patients back into the community due to a lack of social care or beds in community hospitals.
"This is why I wrote to the Secretary of State for Health saying this was a systemic issue. It is not a problem that lies at the door of the South West Ambulance Trust or the Royal Cornwall NHS Trust. It is across the system," he said.
"Unless we get the flow of patients through the hospital, it bottlenecks in the emergency department."
Asked for his view of this, Dr Green replied: "I would agree wholeheartedly."
Dr Green said if the system had been working properly then Col Codd would have been seen by a doctor within an hour and the CT scan would have likely been ordered earlier.
"That may well have shown evidence of the hematoma. I can't say with certainty that it would have done because it was something developing over time," he said.
"That may have given us time to take a different course of action and intervene."
The coroner recorded a narrative conclusion and said he would be writing to the Health Secretary to raise his concerns about delays in the system.
"There was a delay in the arrival of an ambulance and a further delay in his subsequent admission into hospital," he said.
"It is probable that an earlier admission into hospital would have resulted in an earlier CT scan being performed that would have revealed the presence of the hematoma.
"It is possible that if a blood transfusion had taken place, the death would not have occurred when it did."