Norfolk's senior coroner has said a private ambulance firm's lack of a defibrillator had robbed a family of the chance to say their goodbyes to an 81-year-old grandmother who died while in their care.
Jacqueline Lake, senior coroner for Norfolk, gave a narrative conclusion following five days of evidence into the death of Peggy Copeman, from New Buckenham, who died in an M11 layby while being driven back to Norfolk - having been sent 280 miles away for mental health treatment.
And Mrs Lake also issued a second prevention of future deaths report to Premier Rescue Ambulance Service (PRAS), the firm who carried her, after judging it had not done enough to redress the failings that contributed to her death.
Mrs Copeman had been sent to Taunton in Somerset on December 12 after the Norfolk and Suffolk NHS Foundation Trust was unable to find a bed for her locally.
She died on December 16 2019 after going into cardiac arrest while being transported back by PRAS.
Her medical cause of death was given as fatal ventricular arrhythmia caused by ischemic heart disease, though Mrs Lake was concerned PRAS did not act promptly contributing towards Mrs Copeman's death.
Mrs Lake said: "Peggy Copeman died from a fatal ventricular arrhythmia as a result of ischemic heart disease.
"Her death has been escalated by a short time by not being recognised and acted on whilst being transported on December 16 2019."
Mrs Lake said evidence suggested Mrs Copeman would not have survived a hospital discharge but added the use of a defibrillator may have allowed her family to see her and "say their goodbyes and for her to die in an appropriate and dignified setting."
Dr Solanke, the ward doctor at Cygnet Hospital, said after watching CCTV had he seen Mrs Copeman slouched over he would have taken a physical observation before she left.
Mrs Lake said: "I am of the view it is important for patients to be checked out before travelling especially such a long distance to ensure they are fit to travel.
"Certainly for the health benefits of the patient at the very least in some way to reassure a family their loved one is indeed fit to travel."
The court heard staff thought Mrs Copeman was "snoring" during the journey and had not recognised she was in respiratory or cardiac distress.
Referring to evidence given by cardiology expert Dr Khalid Khan, PRAS staff's evidence was "not credible from a medical or cardiological perspective" that Mrs Copeman was breathing normally until the vehicle pulled up on the hard shoulder and highly improbable she would suddenly enter aysytole - the most serious form of cardiac arrest.
A prevention of future death's report had already been sent to PRAS but following her conclusion, Mrs Lake raised further concerns.
Concluding the inquest Mrs Lake said she had taken the "unusual step" to raise the report prior to the inquest because she thought it could prevent future deaths and felt PRAS had not taken concerns raised seriously.
She added that it was not until the CQC became involved that details in her report had not started to be taken.
Mrs Lake said: "That occurred about 18 months after Mrs Copeman's death.
"I do have concerns some of these steps are still outstanding."
She did not issue any reports to the Norfolk and Suffolk Foundation Trust (NSFT) or Cygnet Hospital as she felt the concerns raised before and during the inquest had been "taken seriously" by both organisations.
The hearing's final witness before Mrs Lake's conclusion was Susan Graham, service director from NSFT, who discussed a report that followed into the lack of beds available in Norfolk and Suffok which was the reason Mrs Copeman was transferred out of the county.
She claimed no older adults had been sent out of the county since Mrs Copeman's death.
She told the court of the opening of Blicking Ward, with 21 older adult beds, Mrs Graham told the coroner this being funded by the trust but it would keep the beds open regardless of funding.
Mrs Lake asked about the trust's involvement with the repatriation of out of area patients, and the trust did not make the decision but have input into the transfer.
The trust said clinicians would also make decisions in relation to patients' repatriation after an investigation found staff was "feeling pressured" into decisions into Mrs Copeman's return.
Mrs Graham said: "On reflection, they [senior executive team] should have involved the clinical team that did understand the care and knew of Peggy
"The executive team are there to ensure the clinicians' decision making is robust."
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