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Businessman’s six hour wait for an ambulance

By Ashbourne News Telegraph  |  Posted: December 30, 2013

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A RETIRED company director who was forced to wait more than six hours for an ambulance later died in hospital from diabetic complications.

Flooding which blocked off the A38 and extreme weather conditions saw East Midlands Ambulance Service “struggling to cope” on the day Rodney Butcher became seriously unwell.

The 76-year-old had developed a severe infection and his GP had requested an ambulance to take him to hospital within four hours.

But, when the ambulance did not arrive on time, concerned staff at Mr Butcher’s nursing home rang 999 twice.

And an inquest into his death heard these calls actually made the situation worse, because they cancelled out the original request for an ambulance and caused further delay.

It meant Mr Butcher, of Asbourne, arrived at the Royal Derby Hospital more than two hours later than planned and was taken straight to A&E, where he later died.

Although the inquest heard the delay did not contribute to his death, EMAS said it had now reviewed its policy on how it deals with separate calls to a single incident.

After the inquest, Mr Butcher’s family said they want to thank the ambulance service for “putting their hands up” over the mistake.

And brother-in-law David Pinder said: “In life, he was a fine man, a fine husband, a fine father, brother and uncle and he didn’t deserve to die as he did.

“He’d been a businessman and, for many years, he worked hard for his family and was successful. He wasn’t ready to die and it’s a sad matter that he did.”

Derby and South Derbyshire Coroner’s Court heard how Mr Butcher was receiving respite care at the Old Lodge Nursing Home, in Etwall, in November 2012.

At the time, Mr Butcher, of Shirley Common, was suffering from type-two diabetes, Parkinson’s and Alzheimer’s disease.

Signs of a bladder infection prompted staff at the home to call an out-of-hours emergency care practitioner, from Derbyshire Health United, to take a look at him.

The inquest heard the practitioner, Stephen Meakins, diagnosed Mr Butcher with a urinary tract infection.

He was put on antibiotics and care home staff were told to seek further medical help if his condition deteriorated.

They were also told to monitor his ketone – the by-product when the body cannot use glucose for energy and starts to break down other tissues, such as muscles – and blood-sugar levels.

The court was told how, three days later, Mr Butcher’s condition had worsened and he had started vomiting.

Registered nurse and deputy care home manager Tijo Sebastian told the hearing how he was concerned and called in Dr Michael Vickers, GP at the Wellbrook Medical Centre, for another check-up.

The inquest heard how Dr Vickers saw Mr Butcher at 2.30pm.

Dr Vickers diagnosed Mr Butcher with “uncontrolled diabetes and possible urinary sepsis”.

He said: “It was fairly apparent he needed to be in hospital.”

The court heard Dr Vickers returned to his surgery and, at 2.50pm, requested an ambulance to arrive within four hours and take Mr Butcher to the medical assessment unit at the Royal Derby.

Dr Vickers said, on reflection, he should have called for an ambulance within two hours – but the inquest heard this would have been equally difficult for EMAS given the weather conditions.

It was told how, at 7.34pm, Mr Sebastian rang 999 because he was concerned by the ambulance delay and said Mr Butcher had deteriorated and was “very pale”. He also rang 999 at 8.11pm.

But Alison Crowe, service delivery manager for the emergency operations centre at EMAS, told the inquest how this “masked” the original call.

She said this was because the original request for an ambulance was effectively cancelled and replaced by the new request.

The ambulance eventually arrived at the care home at 9.27pm and reached the hospital at 10.28pm.

Ms Crowe said policies had now been reviewed and guidelines “clearly laid-out” to avoid this issue arising again.

She said a “serious investigation” was carried out by EMAS because of the delay in getting to Mr Butcher and the fact he later died.

Ms Crowe said the trust had already put its “over-capacity” plan in place because of extreme pressure that day – with staff struggling to get to their stations because of flooding and bad weather.

Ms Crowe said there was also a “spike” in emergency calls compared to the same day the previous year and an increase in the time it was taking for paramedics to hand over patients at the Royal Derby.

But assistant coroner Paul McCandless, recording a narrative conclusion, said it was “more likely than not” Mr Butcher would have died even if he had arrived at hospital on time.

The medical cause of Mr Butcher’s death was given as diabetic ketoacidosis – a condition caused by high blood glucose levels because the body cannot use the glucose for energy.

The court was told this was due to haemorrhagic cystitis – inflammation of the bladder caused by an infection.

After the inquest, a spokesman for EMAS said: “We acknowledged we could have responded to this call earlier and would like to pass on our apologies to Mr Butcher’s family.

“We have reviewed our policies on how we deal with separate calls to an incident to make sure this does not happen again.”


Rodney Butcher died on November 27, 2012, at the Royal Derby Hospital of physiological derangement due to a raging and overwhelming haemorrhagic cystitis.

He had been noted to be unwell with haematuria around November 23, 2012. Subsequently, there was proportionate and focused care treatment afforded to him by his nursing home, an emergency care practitioner and a general practitioner.

By November 26, he had taken such a turn for the worst that admission to the medical assessment unit was agreed, to take place by 6.50pm at the latest.

Unfortunately, and in part due to the way that the original call for an ambulance was handled, his transportation to hospital was delayed until 10.28pm.

By this time, and notwithstanding best efforts of emergency department staff, he was already dying.

A through-going inquiry has established that, it is more likely than not, that Mr Butcher was so poorly that, even if he had arrived at hospital either in time, that day, or even the day before, death would have ensued.

THE family of Rodney Butcher have described him as a “family man, business man and extremely well-known in Derby.”

After the inquest into his death, his wife, Susan, said her husband started the firm Creative Interiors, in 1968, and sold it on in 1990. The name still exists today.

She said her husband had also been a member of the Derby Rowing Club since the age of 16 and later went on to be its vice-president.

Mrs Butcher said: “Both myself and my husband were interested in restoring old properties, so we set up a building company to do it.

“One of our heritage restoration projects was Sinai Park House, in Burton.

“Even when he retired, he carried on doing jobs.”

Daughter Bexy Butcher also thanked Old Lodge Nursing Home for the care they gave her father.

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