Coroner concerned paramedics attempted resuscitation for 'only 21 minutes' after man collapsed in shopping centre

Mark Bennett, a 38-year-old IT worker from Grimsby, collapsed when he was shopping with his parents in Boots at Meadowhall in April last year.

An inquest heard he suffered a pulmonary embolism caused by deep vein thrombosis (DVT) – a clot which formed after he sprained his ankle during a fall in London nine days earlier.

In a report, Coroner Steve Eccleston said paramedics did not arrive on the scene for more than 50 minutes due to a delay “caused by pressures on the ambulance service and an error in ambulance allocation”.

He also said paramedics attempted resuscitation “for only 21 minutes” and did not take Mr Bennett to hospital for a treatment called thrombolysis, which breaks down blood clots.

“Guidance and protocols available for ambulance staff and paramedics on when to stop resuscitation and take to hospital for attempts at thrombolysis in these circumstances were unclear,” he wrote.

“I believe there is a lack of guidance and protocols on what constitutes best practice on this issue for paramedics and ambulance staff which might place future patients at risk in similar situations.

“In particular, how long should resuscitation continue for and when should a patient be taken to hospital for thrombolysis.”

The inquest was told staff at Boots attempted CPR after Mr Bennett collapsed and a 999 call was made at 2.10pm. It was recorded as a Category 2 incident, meaning paramedics should aim to respond in an average time of 18 minutes.

Another call was made at 2.47pm when Mr Bennett stopped breathing, meaning it should have been upgraded to a Category 1 incident and responded to in around seven minutes.

However, the ambulance was not dispatched for another nine minutes and it arrived at Meadowhall at 3.03pm.

A spokeswoman for Yorkshire Ambulance Service said it has “acknowledged the concerns raised on the clinical management of a patient in cardiac arrest who has a suspected pulmonary embolism, and how long resuscitation should continue”.

She added: “Nationally, ambulance clinicians follow standard clinical practice guidelines developed and managed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).

"The JRCALC guidelines relating to the management of cardiac arrest follow the Resuscitation Council (UK) guidelines.

“Paramedics are supported to make decisions about the termination of resuscitation attempts and JRCALC provides clear guidance on the scope in which they may make these difficult decisions.

"Sadly, in this instance, but clearly with the best of intentions, a decision was made which falls outside of this scope.

“As a result, we are reviewing and updating our clinical documentation to better support clinicians in their decision making and will be including a component on decisions relating to the termination of resuscitation attempts in annual clinical refresher training.

“Our thoughts remain with Mark Bennett’s family.”

Mr Bennett had visited A&E at Grimsby’s Diana Princess of Wales Hospital three days before his death, complaining of a pain in the back of his right leg, but was told he only had a sprained ankle.

A letter sent to Mark’s GP found that his calf had been examined and was “soft and non tender”. The main features of DVT are swollen veins that are hard and painful to touch, as well as swelling.

He was not prescribed medication to prevent a DVT but was told to return for a follow-up appointment in three weeks.

However, the inquest was told a clot could have developed in his veins after the hospital visit.