Chloe Felicity Dugdale Simpson was left with paramedics as the Norfolk and Norwich Hospital's (N&N) emergency department struggled to cope with demand, with no beds available to admit her.

Norfolk Coroner’s Court heard the 67-year-old went into cardiac arrest in the vehicle after deteriorating rapidly while crews waited to hand her over.

Although area coroner Yvonne Blake ultimately ruled her death was due to natural causes linked to undiagnosed cancer, she raised serious concerns about hospital overcrowding, handover delays and communication failures.

Norfolk and Norwich Hospital (Image: Newsquest)

EXTREME PRESSURES AT A&E

Mrs Simpson, from Norwich, died on February 6 last year after suffering weeks of worsening abdominal pain and vomiting, with blood appearing in her vomit in the days before her death.

Paramedics were called to her home at 3.58pm that day, where she described severe stomach pain and told crews she had been unwell for weeks.

She was taken to hospital, arriving at the N&N's emergency department at around 6.09pm, but due to overcrowding was taken for blood, then returned to the ambulance to wait for a bed while being monitored in the car park by paramedics.

The inquest heard the department was under extreme pressure, with more than 100 patients in A&E, dozens waiting for beds and at least 15 ambulances queued outside.

The incident had been categorised as a stage four emergency.

Area coroner Yvonne Blake (Image: Denise Bradley)

Because no space was available, Mrs Simpson remained in the ambulance under paramedic care. During this time crews monitored her condition, gave pain relief and later administered fluids as her blood pressure began to fall.

When shift change occurred, handovers between ambulance crews took place and Mrs Simpson was moved to a different vehicle.

Paramedic Mark Wright told the court Mrs Simpson was conscious but in significant pain, rating it “10 out of 10”.

He administered morphine but was unable to give further doses as her blood pressure began to drop.

“She said the pain relief didn’t help, but her blood pressure was falling so we were concerned about giving more,” he said.

Fluids were given in an attempt to stabilise her condition, and the coroner heard this had been advised when she first arrived at hospital but there was no evidence it had been carried out.

At around 9.40pm doctors reviewed her in the ambulance and became concerned about how unwell she appeared.

Minutes later her condition worsened rapidly with one medic describing her as looking “grey”.

At 10.05pm assistance was urgently requested to move her into resuscitation. By that stage she was struggling to breathe effectively and soon after went into cardiac arrest.

CPR was started as she was rushed into the resuscitation area, where further advanced life support was delivered, including defibrillation.

Despite efforts to revive her, Mrs Simpson was pronounced dead at 10.25pm.

Norfolk and Norwich University Hospital (Image: Newsquest)

A post mortem later revealed she had advanced bowel cancer which had spread, alongside significant heart disease. The medical cause of death was recorded as natural causes resulting from cancer and associated complications.

Coroner Mrs Blake said earlier hospital treatment would not have altered the outcome.

However, the inquest heard Mrs Simpson had spent approximately three hours and 30 minutes waiting outside in the ambulance before her sudden collapse.

Mrs Blake described the conditions in the emergency department as chaotic, comparing the noise and confusion to “a trading floor” and even “Dante’s Inferno”.

She said verbal handovers were difficult due to the environment, raising concerns vital information could be missed.

'LESSONS MUST BE LEARNED'

One of Mrs Simpson’s sons said while he accepted that earlier treatment would not have saved their mother, lessons must be learned.

“There needs to be something to highlight what has happened here so improvements can be made for the future,” he told the court.

He added confusion over blood test results and whether fluids had been administered showed how breakdowns in communication could affect patient care.

He added: “I agree with the coroner’s assessment that it probably wouldn’t have changed anything for our mum, but it could change something for someone else.”

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

The court heard Mrs Simpson, widowed 18 months earlier after 40 years with her husband, had been living independently but struggling following his sudden death.

Paramedics remained with her throughout the wait, and the coroner noted some patients may in fact be safer under constant ambulance supervision than waiting alone in hospital corridors.

However, she expressed concern about ambulance queues caused by delays discharging patients from hospital beds due to social care shortages.

Addressing Mrs Simpson’s family, she said: “I am very sorry. Your mother was very unwell, and sadly she was going to die anyway, but improvements could help others.”

The coroner announced she would consider issuing a Prevention of Future Deaths report to both the hospital and ambulance service, calling for improvements to handover procedures and communication systems, if she was not satisfied that improvements had been made already.

Among her recommendations were ensuring handovers take place in quieter areas and improving systems so blood test results are automatically available across NHS services.

Mrs Simpson’s sons said they took comfort in knowing their parents were now reunited, adding: "We take solace that mum died quickly and in the fact that they are back together."

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