Avoidable death of young man following road traffic accident

What happened

Mr P, who was in his early twenties, was involved in a road traffic accident with a car while on his motorbike. He suffered extensive facial injuries. An ambulance crew from Great Western Ambulance Service NHS Trust, consisting of a paramedic and an emergency care assistant arrived on the scene and were there for about 20 minutes. The journey to hospital took approximately five minutes. Sadly, by the time Mr P arrived at the hospital, his heart had stopped beating, and he was pronounced dead shortly after.

What we found

Overall, apart from the crew's initial assessment of Mr P, which seemed in line with established good practice given the circumstances, the rest of the ABCDE (Airway Breathing Circulation Disability Exposure) assessment was completely inadequate.

Mr P's airway was obstructed at some stage and during the five‑minute ambulance journey to the hospital his airways became 'full of blood'. We concluded that his airways became obstructed by blood while he was in the ambulance. Given the absence of any record to the contrary, it is more likely than not that no, or insufficient, attempts were made to clear Mr P's airways during those five minutes. This clearly fell significantly below what should have happened, and amounted to service failure.

Our emergency medicine adviser said that when Mr P suffered a cardiac arrest in the ambulance, the ambulance should have stopped and the emergency care assistant joined the paramedic in the back to help with resuscitation. This did not happen.

We concluded that the service failure directly contributed to Mr P's death, because one of the failings was that there were no or insufficient attempts to clear or assess his airways while he was in the ambulance. Had the paramedic crew given Mr P appropriate care, his death could have been avoided.

Mrs T has lived with the grief of losing her son and believing that he could have been saved. There is no doubt that this has been a source of profound distress for her, caused by the service failure we identified.

Putting it right

The Trust (now South Western Ambulance Service NHS Trust) apologised to Mrs T and paid her £15,000 in compensation. This Trust has taken over from Great Western Ambulance Service NHS Trust which provided the service at the time of the events. So, rather than asking this Trust to provide an action plan for failings it was not responsible for, we asked it to give a statement that described how its service would make sure that incidents such as this one are learnt from today. It has done this.