Connor Matthews, 20, died after waiting more than three hours for a London Ambulance Service ambulance that should have arrived in 18 minutes, an inquest heard this week. The case has drawn attention from Canadian paramedics who say the systemic failures exposed in the hearing feel familiar.
Ambulance service overwhelmed by call volume
Previously fit and healthy Connor Matthews passed away when a routine sinus infection invaded his brain. Inner West London Coroner's Court heard that on the day he became unwell, London Ambulance Service (LAS) was "overwhelmed" by the sheer number of calls it was receiving. Further delays to his treatment meant he died sooner than he otherwise would have, experts said.
Although staffing was "above plan," 250 ambulance hours were lost that day thanks to handover issues at hospitals and LAS was dealing with the "significant pressure" of 250 calls an hour as well as 75 similarly graded calls at the same time. Canadian emergency departments report nearly identical offload delays that tie up crews for hours. Mr Matthew's 999 call was graded correctly as category two, which should have seen attendance in an average of 18.5 minutes, but instead he waited while drifting in and out of consciousness for 3 hours 21 minutes.
Senior Quality Assurance Manager Lyn Sugg apologised to the family at the hearing, saying: "I'm sorry we weren't able to do better for Connor on that day, we were just overwhelmed."
The inquest heard that the 20-year-old road traffic manager had a routine case of sinusitis that had become invasive, causing pus in the brain, meningitis and swelling. At an inquest into his death, experts said that by the time he arrived at hospital there was very little that could be done to save him. Independent witness Carl Hardwidge said Mr Matthews would have had to have presented at A&E 48 hours before he did to have been in with a chance of survival.
However a series of delays to his care as well as the fact that he wasn't given a breathing tube, known as intubation, for hours after presentation were described by senior coroner Professor Fiona Wilcox as "concerning."
Hospital transfer delays compound tragedy
Mr Matthews had been suffering from sinus headaches in the weeks prior to his death on July 7, 2023, and on July 3 vomited while at his girlfriend's house. The following evening, Mr Matthews returned to the family home in Uxbridge, west London, where he went to bed, but according to his mum Kim McCarthy he woke up at around 4.30am and was again sick.
The next day, Ms McCarthy assumed he had a stomach bug, but was concerned when she saw him driving off to see friends at around 4.30pm, but struggling to remember how to open the gates on their driveway. Friends and family tried to contact Mr Matthews to check on him and found him trying to walk to his nan's house in a state of confusion and holding onto railings to keep himself upright.
He was driven to his grandmother's home where he began hallucinating, was drifting in and out of consciousness and lost the ability to speak. An ambulance was called at 6.52pm on July 5, but due to incredibly high demand that day, one did not arrive until 10.15pm.
When Mr Matthews did arrive at Hillingdon Hospital at 10.28pm, it became obvious that he was in a very serious condition with a suspected brain injury. He had two scans which showed midline shift, an ominous medical sign that shows the brain has swollen and moved past its usual centre point, as well as an infection and abscess. Specialist neurosurgeons at St Mary's Hospital in Paddington were contacted and it was agreed he would be transferred for urgent brain surgery.
However much debate centred around the fact that Mr Matthews was not intubated at Hillingdon, which would have protected him from further brain damage if his condition had deteriorated. Dr Vilas Pangrekar, of Hillingdon Hospital, said it would have taken around an hour to have given the patient a breathing tube and he had not wanted to slow his transfer down. "In this situation I think the priority was to get him treatment. He needed the surgery and to get it as quickly as possible," he said.
Consultant neurosurgeon Carl Hardwidge was called in to review the case for the coroner. He said from the point of his arrival Mr Matthews would only deteriorate until he was given surgery, so he believed he should have been intubated as soon as possible. When he did arrive at St Mary's at 02:40am on July 6, there was a further 2.5-hour delay to surgery while a hematologist was sought for advice on clotting.
His Glasgow Coma Scale, used to check a person's level of consciousness, was not checked regularly enough and he was not immediately seen by an anaesthetist, which was needed before intubation, the court heard. Several hours later, Mr Matthews suffered a seizure and it was only then that he was given a breathing tube, however by that point his oxygen supply had been cut off and he was effectively brain dead, the court heard.
He was taken for surgery within the hour, but his brain swelling was unsurvivable. Asked if the delays had "accelerated his demise", Mr Hardwidge said: "Yes. Both the delay and lack of intubation has made him die sooner, but he still would have died. If he'd presented a couple of days beforehand then I think he may have stood a chance."
Surgeons performed an evacuation of the infected area of his brain and he was started on multiple antibiotics and anti-fungals, but to no avail. After surgery, his pupils remained fixed and dilated, which treating neurosurgeon at St Mary's, Dr Sophie Camp, said was a sign that was "challenging for survival." Asked how common it was to see people with sinus infections moving into their brains she said: "You see a variety of different types of abscesses, typically from the ear, but we do see a fair few sinus related infections so it is within our scope to manage them."
Mr Matthews died on the evening of July 7, 2023, with his family at his bedside. A post mortem examination by Dr Anna Rycroft found the cause of death as a subdural empyema, a rare, life-threatening intracranial infection where pus accumulates in parts of the brain, as well as meningitis, strokes and increased cranial pressure. She gave his cause of death as due to natural causes and added: "Sinusitis had occurred spontaneously."
Following motorbike-mad Mr Matthew's death, friends raised £6,399 for the family via a GoFundMe appeal. On the day of his funeral, dozens of bikers also turned out to accompany his coffin, taken in a sidecar, to the church. Prof Wilcox gave a narrative conclusion, saying the death was from natural causes, the timing of which was contributed to by treatment delays and a lack of timely intubation. She added: "I would like to pass my sympathies to Connor's family and friends. He was obviously a delightful young man who made the best of his life. He was living his life to the full and I'm sorry he was taken from you in such a sudden and traumatic way."