Connor Matthews, 20, died after waiting more than three hours for a London ambulance that should have arrived in about 18 minutes, an inquest heard. The previously fit and healthy road traffic manager had a routine sinus infection that invaded his brain.
Inner West London Coroner's Court heard that on the day he became unwell, London Ambulance Service (LAS) was “overwhelmed” by the number of calls it was receiving. Experts said further delays to his treatment meant he died sooner than he otherwise would have.
Ambulance service overwhelmed
Although staffing was “above plan”, 250 ambulance hours were lost that day due to handover issues at hospitals. LAS was dealing with the “significant pressure” of 250 calls an hour, as well as 75 similarly graded calls at the same time.
Mr Matthews’ 999 call was graded correctly as category two, which should have seen attendance in an average of 18.5 minutes. Instead, he waited while drifting in and out of consciousness for 3 hours 21 minutes.
Senior Quality Assurance Manager Lyn Sugg apologised to the family at the hearing, saying: “I’m sorry we weren’t able to do better for Connor on that day, we were just overwhelmed.”
Timeline of events
Mr Matthews had been suffering from sinus headaches in the weeks prior to his death on July 7, 2023. On July 3, he vomited while at his girlfriend’s house. The following evening, he returned to the family home in Uxbridge, west London, where he went to bed. His mother Kim McCarthy said he woke up at around 4.30am and was again sick.
The next day, Ms McCarthy assumed he had a stomach bug, but was concerned when she saw him driving off to see friends at around 4.30pm, struggling to remember how to open the gates on their driveway. Friends and family found him trying to walk to his nan’s house in a state of confusion, holding onto railings to keep himself upright. He was driven to his grandmother’s home, where he began hallucinating, drifting in and out of consciousness, and lost the ability to speak.
An ambulance was called at 6.52pm on July 5, but due to high demand, one did not arrive until 10.15pm. When Mr Matthews arrived at Hillingdon Hospital at 10.28pm, it became obvious he was in a very serious condition with a suspected brain injury.
Hospital care and delays
Two scans showed midline shift – an ominous medical sign that the brain has swollen and moved past its usual centre point – as well as an infection and abscess. Specialist neurosurgeons at St Mary’s Hospital in Paddington were contacted, and it was agreed he would be transferred for urgent brain surgery.
However, debate centred on the fact that Mr Matthews was not intubated at Hillingdon, which would have protected him from further brain damage if his condition deteriorated. Dr Vilas Pangrekar, of Hillingdon Hospital, said it would have taken around an hour to give the patient a breathing tube and he had not wanted to slow his transfer down. “In this situation I think the priority was to get him treatment. He needed the surgery and to get it as quickly as possible,” he said.
Consultant neurosurgeon Carl Hardwidge, who reviewed the case for the coroner, said from the point of arrival Mr Matthews would only deteriorate until he was given surgery, so he believed he should have been intubated as soon as possible.
Further delays at St Mary's
When Mr Matthews arrived at St Mary’s at 2.40am on July 6, there was a further 2.5-hour delay to surgery while a hematologist was sought for advice on clotting. His Glasgow Coma Scale was not checked regularly enough, and he was not immediately seen by an anaesthetist, which was needed before intubation, the court heard.
Several hours later, Mr Matthews suffered a seizure, and it was only then that he was given a breathing tube. However, by that point, his oxygen supply had been cut off and he was effectively brain dead, the court heard. He was taken for surgery within the hour, but his brain swelling was unsurvivable.
Asked if the delays had “accelerated his demise”, Mr Hardwidge said: “Yes. Both the delay and lack of intubation has made him die sooner, but he still would have died. If he’d presented a couple of days beforehand then I think he may have stood a chance.”
Conclusion
Surgeons performed an evacuation of the infected area of his brain, and he was started on multiple antibiotics and anti-fungals, but to no avail. After surgery, his pupils remained fixed and dilated, which treating neurosurgeon at St Mary’s, Dr Sophie Camp, said was a sign that was “challenging for survival.”
Mr Matthews died on the evening of July 7, 2023, with his family at his bedside. A post-mortem examination by Dr Anna Rycroft found the cause of death as a subdural empyema (a rare, life-threatening intracranial infection where pus accumulates in parts of the brain), as well as meningitis, strokes, and increased cranial pressure. She gave his cause of death as due to natural causes and added: “Sinusitis had occurred spontaneously.”
Senior coroner Professor Fiona Wilcox gave a narrative conclusion, saying the death was from natural causes, the timing of which was contributed to by treatment delays and a lack of timely intubation. She added: “I would like to pass my sympathies to Connor’s family and friends. He was obviously a delightful young man who made the best of his life. He was living his life to the full and I’m sorry he was taken from you in such a sudden and traumatic way.”
