Concerns raised over lack of response time target in some life threatening 999 calls in inquest into death of head teacher and Man Utd talent scout Tony Hopkins

Caroline Saunders made the comment while summing up at an inquest into the death of a former Newport head teacher and talent scout for Manchester United, who died following a fall at his home.

Tony Hopkins, 74, waited almost two hours for an ambulance at his home in Bassaleg, Newport, after falling down the stairs on the morning of Sunday, January 13, this year.

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The former head teacher at what was then Monnow Junior School in Bettws was found on the hall floor by wife Angela. He was in pain and could not feel his legs.

The first 999 ambulance call, at 9.45am, was initially categorised as 'green three', or non-urgent, with Mr Hopkins described as conscious and alert.

But this was changed to 'amber one' during the four-minute call, after it was ascertained that Mr Hopkins had a form of bone cancer, and may have fallen over a bannister.

As that morning progressed, his condition deteriorated. During a 10.57am call to the house made by an ambulance service dispatcher, Mr Hopkins was described as being in "agony" and "hot and clammy". In a call at 11.31am, he was described as unconscious, with ineffective breathing.

The call was reclassified as 'red', the most serious. An ambulance was sent four minutes later, but when it arrived at 11.42am, Mr Hopkins was in cardiac arrest. He was pronounced dead at 12.20pm.

A post mortem examination revealed Mr Hopkins had suffered multiple spinal and sternal fractures.

Ms Saunders was told that a Welsh Ambulance Services NHS Trust (WAST) report into the case indicated that at 9.57am it had been noted there were "no emergency resources to allocate" to the initial 999 call, and a group call at 10.44am to identify unallocated crews who may have been on a break was unsuccessful.

Kate Blackmore, WAST area manager for clinical contact centres, confirmed that despite 'amber one' calls being considered life-threatening emergencies, there is no response time target. Such calls encompass chest pain, stroke, and fractures.

But she said that in general, she would expect the average response time for such a call to be "around 30 minutes", dependent on demand.

She had no details of demand that day, but said she would have expected it to have been higher than average as it was winter, and hospital handover delays may have further affected the situation.

Addressing members of Mr Hopkins' family, Ms Blackmore offered "apologies for the service you received".

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Darryl Collins, WAST's head of patient concerns and learning, said there had been an available Rapid Response Vehicle in Chepstow at the time, but this was ring-fenced for that area.

He told family members he was "deeply apologetic on behalf of the organisation" for the delay.

Mr Hopkins' daughter Lisa told Ms Saunders the family felt a faster response could have prevented a situation where her father's vertebrae "impacted so severely on the spinal cord that it prevented him from breathing".

They felt this was not "a straightforward accidental death", she said, because it could have been prevented by a faster response.

Ms Saunders said the lack of a response time target for amber one calls is "a situation I must admit I find extraordinary", and noted the "considerable delay" in the ambulance attending.

But she said she had seen no evidence that had it attended earlier, Mr Hopkins would have survived.

Conclusion: Accident.