Family suing NHS after OAP chokes to death in pub 300 yards from ambulance yard

A grieving family are suing the NHS after a pensioner choked to death in a pub just yards from an ambulance station – despite an inquest ruling the death as accidental.

Yukio Nishigaki, 83, passed away two days after a piece of meat became lodged in his throat while having a meal with his granddaughter.

An inquest heard how it took almost half an hour for paramedics to begin appropriate treatment because they could not find the right equipment.

The tragedy occurred at the Royal Oak pub, which is located just 300 yards away from an ambulance hub in Evesham, Worcestershire – but there was no unit based in the town that day.

However, the inquest ruled by Worcestershire Coroner Gearint Williams concluded the error could not be conclusively pinpointed as the cause of Mr Nishigaki's death.

His family are now taking legal action to kick-start "systemic change" within the NHS and ensure ambulances are stationed closer together in rural areas.

Mr Nishigaki's daughter-in-law Emma Nishigaki, 51, said: "We are currently at the stage of writing a letter of intent to West Midlands Ambulance Service.

"Our main motivation is that we want the organisation responsible to be down on record as accountable.

"If things like this don't happen there is no incentive to change policy.

"They have changed policy when it comes to having an ambulance based in Evesham but that is only because they have been shamed into it.

"They tried very hard to justify that (the old policy) in the coroner's court and in our minds, it was not so much about the errors that happened on site, because they were made without malice, intent or foresight, but the decisions from above.

"The thing that really struck me in the inquest was how young the paramedic was.

"He was devastated by what had happened and the mistakes that we were made were through being under so much pressure and that was caused by the location of ambulances.

"They were made to cut costs. Three land ambulances came in the end, all of them had been on category three (urgent but not life-threatening or emergencies) or less urgent calls.

"In my mind, one of those ambulances should have been ringfenced in the area in case a category one (life-threatening) call came in.

"There was not even a Rapid Response vehicle in the area. Their argument is that a dynamic system where ambulances are sent to the highest category job is in place.

"But the argument against that is that 12 minutes is too long for time-critical responses like someone choking or a cardiac arrest.

"The system probably works well in built-up areas and metropolis-type regions but when you have towns in the middle of rural areas, it leads to this type of problem.

"They say having an appliance sat waiting is a wait, I say that risks wasting a life. It seems Evesham itself was left completely bereft."

The nearest crew arrived at the pub on Vine Street within 11 to 12 minutes of being called to the pub on March 14, 2020.

Yukio's granddaughter and a waitress performed CPR until paramedics arrived to take over.

But there was a further 16 to 17-minute delay in issuing appropriate treatment when medics struggled to find a laryngoscope – which is used to examine the throat.

A second crew located the "lost" equipment in another bag but Mr Nishigaki had been starved of oxygen for too long and was placed on life support.

His family were forced to make the heartbreaking decision to turn off his life support machine in hospital two days later on March 16.

West Midlands Ambulance Service admitted causing "severe harm" to Mr Nishigaki.

But despite the admission of guilt from the ambulance service, the Coroner still ruled that the NHS could not be held at fault for the death.

However, the daughter-in-law and Councillor for Avon Ward in Evesham, Emma Nishigaki, disagrees with the result.

She said: "They say that even if an ambulance had been stationed in Evesham, there is no guarantee it would have been available.

"Our response to that is yes, it is possible it would have been on another shout but if there is no ambulance based there in the first place then there is no chance of it being available.

"It is our belief that systemic failings in the ambulance service, particularly the positioning of ambulances, led to his death.

"Nobody acted with malice or bad intent, they were working under extreme pressure and I believe that was created by how long it had taken to get to him.

"We don't hold any individual responsible for his death, it was a symptom of the systemic failures in the way that they deploy ambulances, making it likely that anyone with a time-critical emergency having a negative outcome."

A West Midlands Ambulance Service spokesperson said: "Our thoughts remain with the family of Mr Nishigaki.

"The trust carried out a full review of the circumstances surrounding his death and made a number of changes based on those findings such as ensuring that the Evesham Community Ambulance Station is fully staffed and a crew is operational from there each day.

"The placement of ambulances is based on detailed research and modelling and is kept under constant review.

"The trust has the best response performance in the country but we will continue to do everything possible to improve these still further."

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