Suffolk woman Gina Bywater, 36, died after near 10-hour ambulance wait, as senior coroner Nigel Parsley calls for action

A coroner has called for action to be taken after a near 10-hour wait for an ambulance ‘directly contributed’ to a woman’s death.

Gina Bywater, 36, was declared dead at her Suffolk home on December 13 last year, having become unwell with vomiting and shortness of breath at about 10pm the night before, according to a coroner’s report published yesterday.

Three calls were made to the ambulance service but one did not arrive until nearly 10 hours after the first.

An East of England Ambulance Service spokesperson apologised to her family and said that response times had improved since the start of 2023, but recognised there was a lot more work needed.

A first 999 call was made at 12.01am, but due to high demand and some crews waiting to offload patients, an ambulance was not immediately available.

An hour later, another call was made after Gina started suffering chest pains, before a third followed at 4.07am.

Once again, no crews were free.

These were considered category two calls, with an estimated average response time of 40 minutes, and a target of 18 minutes.

The East of England Ambulance Service made a welfare call at 9.36am, during which it was found that Gina had gone into cardiac arrest.

This resulted in a category one response, and an ambulance arrived for Gina at 9.45am.

A post-mortem examination found Gina died of a heart attack.

In a prevention of future deaths report, Senior Coroner Nigel Parsley said he believed that the delay in an ambulance attending meant that lifesaving treatment could not be given, which directly contributed to Gina’s death.

His conclusion was that Gina died of natural causes due to an untreated cardiac condition.

The medical cause of death was confirmed as acute myocardial infarction alongside a fatty liver, pancreatic cyst and fibrosis.

Mr Parsley said: “During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken.

“There are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region.

“These periods – in this case nearly 10 hours – fall far short of the target times set by the East of England Ambulance Trust itself.”

An expert cardiologist suggested a timely arrival of an ambulance, alongside drugs given by paramedics and early transport to hospital, could have saved her life ‘on a balance of probabilities’, according to the report.

“I am therefore concerned the continuing lack of sufficient ambulance resourced in Suffolk will lead to a future loss of life,” Mr Parsley said.

The coroner called on the East of England Ambulance Service to take action to prevent future deaths – and believed it had the power for change.

He gave the trust 56 days to respond, asking it to detail what action will be taken, as well as a timetable of when it will happen.

The East of England Ambulance Service spokesperson said: “We would like to offer our sincerest apologies to Gina Bywater’s family for the delayed response.

“We have noted the coroner’s comments to the Secretary of State and will consider them carefully.

“As we related to the inquest, at the time of this incident the Trust was under significant pressure due to 999 call volume and hospital handover delays.

“Since the start of 2023 our response times have improved due to work to increase the number of frontline staff and available ambulances, but we recognise there is a lot more work needed by us and our partners to improve our response to patients.

“Our thoughts remain with the family and friends of Gina Bywater at this time.”