Jean Groves, 75, who lived independently at her home in Long Stratton with support from carers, died after no one was able to enter her home before help reached her.   

An inquest into her death at Norfolk Coroner’s Court last year heard she died due to an acute upper gastrointestinal haemorrhage.  

She also had an underlying condition of ischaemic heart disease.  

Area coroner Johanna Thompson (Image: The Coroners' Society)

Johanna Thompson, an area coroner for Norfolk, concluded her death was due to natural causes, but raised concerns that shortcomings in emergency response systems could place other vulnerable people at risk.   

She issued a Prevention of Future Deaths (PFD) report to Careline365 and Swift at Norfolk County Council and stated that her investigation had revealed matters of concern that could pose a risk to others if not addressed. 

She 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. 

“I have concerns that if emergency responders are not being provided with access details for vulnerable patients when providing support to the ambulance service under the NHS ‘Access to the Stack’ initiative, this may lead to future deaths.”    

Norfolk Coroner's Court, at County Hall in Norwich. (Image: Newsquest)

Ms Groves had a complex medical history from an early age, which included learning difficulties, and developed dementia in later life.    

She was diagnosed with stomach ulcers in 2021 and was prescribed medication to reduce stomach acid.    

Despite her health conditions, she lived at home with regular carer support and had a personal alarm system in place for emergencies.   

The report continues that in the days leading up to her death last year, Ms Groves had been unwell. From March 21 she experienced diarrhoea and vomiting so took medication supplied by her local pharmacy.    

On March 23, her carer became concerned after noticing that her vomit was dark in colour – a potential sign of internal bleeding.   

A paramedic attended Ms Groves later that same day and recorded her observations as “normal”.  

Norfolk Coroner's Court in Norwich (Image: Denise Bradley)

The next day during the early hours of March 24, shortly before 5am, Ms Groves activated her personal alarm.    

In turn, the alarm service – Careline365 – contacted the East of England Ambulance Service NHS Trust (EEAST), concerned that she had fallen.   

However, due to call categorisation and service demand, an ambulance did not arrive at her home until around 10am – some five hours later.   

The report goes on to explain that the community service - Norfolk Swift Response - had been contacted by the ambulance service under the NHS digital ‘Access to the Stack’ initiative, which allows additional responders to assist during periods of high demand.   

But Swift did not have access details for Ms Groves’ property, meaning no one from the service was able to attend.   

When the ambulance crew eventually arrived at her address on Manor Road, Ms Groves was found to have died.    

In her report, Ms Thompson said: “It is unknown whether her death could have been prevented had she received earlier medical attention.”   

A letter from Swift Response Service was sent to the court in response to the coroner’s concerns. 

It explains that when the duty manager reviewed Ms Groves’ social care record, no access details were listed, and in line with procedure, the referral was declined and returned to the ambulance service.  

However, the manager did not record the declined referral on the system as required - a breach of internal documentation procedures described in the letter as “an internal recording error”.  

The omission did not affect the decision to return the referral but resulted in an incomplete audit trail.  

The duty manager has since acknowledged the mistake and confirmed his understanding of the correct procedure.  

It adds: “To prevent a recurrence of a recording error a communication is being issued to all operational managers and reablement liaison officers responsible for triaging incoming referrals.  

“This will remind staff that every referral...and that all attempts to obtain access details must also be clearly documented to ensure a complete and transparent audit trail.” 

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