A CORONER has said he will be writing to West Midlands Ambulance Service after an inquest was told there was a "missed opportunity" to tend swiftly to an elderly patient who had fallen down the stairs.

Black Country coroner Zafar Siddique concluded 70-year-old Reginald Dixon died by way of accidental death after a suspected fall down the stairs at his home in Orwell Close, Norton.

The retired care worker was taken by paramedics to Birmingham's Queen Elizabeth Hospital after the incident on June 26 but he had suffered a significant brain injury and other fractures and - after a CT scan his wife Dorothy was told his condition was "unsurvivable".

His chances of survival may have been greater, however, had he received medical care sooner - the inquest at the Black Country Coroner's Court, Oldbury, was told on Monday (September 4).

Although emergency calls were made to West Midlands Ambulance Service shortly after the pensioner is believed to have fallen, paramedics did not arrive at the scene until 57 minutes after the first call was made at 6.53pm and Mr Dixon eventually arrived at hospital some two hours after falling.

Giving evidence - Dr David Yeo, consultant in emergency medicine at the Queen Elizabeth Hospital, could not say whether Mr Dixon would have survived given the extent of his brain injury and other fractures and the court was told he was not deemed suitable for neurosurgery on arrival at hospital.

The coroner said: "Even if he’d had surgery that doesn’t mean survivability would have improved because there are a number of complications, including pneumonia, from this type of surgery – particularly for gentleman of 70 years of age."

However - he did say there was a "window of opportunity" for Mr Dixon to have been attended to earlier - as initially he was sitting up when found by neighbours and although in pain he was conscious and talking, but his condition quickly deteriorated and he began vomiting and became drowsy and around 45 minutes after the incident he lost consciousness.

Paramedics arrived some five minutes later - after a fourth call to the ambulance service - and he was taken to the Birmingham hospital where he died later that evening.

A post mortem revealed he died of aspiration of gastric contents due to a significant bleed on brain and multiple fractures.

The coroner said he could not say whether the outcome would have been different had there been no delays in attending to Mr Dixon or if he had been taken to the nearer Russells Hall Hospital in Dudley instead.

But he said he had concerns about how the calls to the ambulance service were categorised.

The first two were graded at category level 3 - and it was only after a third call was made that Mr Dixon was given a higher priority rating for the ambulance service, which the hearing was told, was experiencing high demand that evening.

Mr Siddique said: "This inquest does raise a number of concerns - particularly in relation to the categorisation; the second call that was made and the operator's training in terms of categorising that call. I think that was a missed opportunity. I’m going to write a report to deal with that to try to prevent future deaths occurring - whether that means retraining or further training and further guidance."

He said he was also concerned about the allocation of resources given the busy period the ambulance service was under at the time and he questioned "whether they have sufficient resources to deal with the different influx of demands at peaks and troughs".

He added: "I will write a report to the relevant department asking to see whether any changes can be made."