Fatal Delays: Coroner Condemns NHS Computer Systems and Ambulance Triage

…By Judah Olanisebee for TDPel Media. Tragic Death Exposes Flaws in NHS Computer Systems: Coroner Condemns Ambulance Delays


The recent death of Sandra Finch, who tragically passed away after waiting over 16 hours for an ambulance, has shed light on the dangers of NHS reliance on rigid computer systems.

Despite doctors’ knowledge of her medical conditions and the risks associated with them, a triage system guided by inflexible computer algorithms categorized her as a non-emergency case.

A coroner’s report warns that more lives will be at risk if significant changes are not made.


Inadequate Triage and Delays

Sandra Finch’s health deteriorated after she underwent a dental procedure and began taking antibiotics, which affected her type 1 diabetes management.

She reached out to healthcare services, reporting high glucose levels, sleepiness, vomiting, and the inability to find her blood sugar test kit.

However, when she called emergency services, the computer system misclassified her as a category three case, indicating urgency but not life-threatening.

The system required a clinical review, but no time limit was set for the assessment.


Additionally, the West Midlands Ambulance Service, already understaffed, took ten hours to contact her.

Fatal Consequences of Misclassification

Assistant Coroner Emma Serrano highlighted that a real-life clinician would have promptly recognized the severity of Sandra’s condition and designated her as a category two emergency, warranting an ambulance within 18 minutes.

Tragically, the call back from a clinician occurred ten hours after her initial call, and it took an additional five hours to escalate her case to category two.

When paramedics finally arrived, they found Sandra Finch deceased, having succumbed to ketoacidosis.


Concerns Raised and Urgent Action Needed

Summarizing the inquest’s findings, Ms. Serrano emphasized that the rigidity of the computer-driven triage system resulted in a crucial misclassification of Sandra’s case.

The lack of flexibility prevented the recognition of a potentially serious situation that required immediate intervention.

She expressed concern over the triage pathways’ inflexibility, the absence of time limits for assessments, and the lack of prioritization systems.

Ms. Serrano concluded that unless action is taken, future deaths may occur due to delays caused by these shortcomings.


Response and Pilot Scheme

The Prevention of Future Death Report was sent to various entities, including the West Midlands Ambulance Service, NHS England, and electronic healthcare providers Medtronic Ltd.

The CEO of the ambulance service acknowledged the reliance on computers as part of a pilot scheme aimed at managing patient outcomes and alleviating staff shortages during the COVID-19 pandemic.

The scheme involved clinical triage of category three and four incidents, with a target of contacting patients for clinical assessments within 60 minutes.

Call for Condolences and Improvement


The CEO expressed condolences to the family of Sandra Finch and provided statistics on the percentage of patients referred to alternative services or given self-care advice.

However, the report’s findings highlight the need for further improvement in the referral pathway and overall system performance.

Conclusion: Demanding Change for a Safer Future

The tragic death of Sandra Finch due to ambulance delays and the shortcomings of NHS computer systems underscores the urgent need for change.

The rigid triage process, reliance on algorithms, and lack of flexibility have proven fatal in this case.


The coroner’s report serves as a call to action for the West Midlands Ambulance Service, NHS England, and other involved parties to reassess and improve their systems, ensuring prompt and accurate categorization of emergencies.

Only through such improvements can lives be saved and future deaths prevented.

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