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08 Jul 2021

Actions against public authorities

Welsh law firm instrumental in proving death of much-loved grandmother was ‘accelerated’ by healthcare failings.

In December 2019, Peggy Copeman suffered a cardiac arrest while being transported over 250 miles from a specialist mental health hospital in Somerset to her home county of Norfolk by a private ambulance provider. In lieu of a defibrillator or the provision of adequate first aid, Peggy passed away on the hard shoulder of the M11.

Following the conclusion of the inquest into Peggy’s death on Friday 25th June, Partner and head of the Actions Against Public Authorities team, Craig Court, reflects on this tragic case.

Peggy’s story

A wife and mother of two, Peggy was described by her daughter Maxine as ‘a lovely person, inside and out’.

In the late 1960s, Peggy was diagnosed with paranoid schizophrenia and would go on to receive treatment throughout her life. In 2014, she was moved into a care home after showing signs of dementia.

Following a deterioration in her mental health in 2017, the Norfolk and Suffolk NHS Foundation Trust attempted to source a place for Peggy at a specialist hospital. The closest available bed was at the Cygnet Hospital in Taunton, Somerset, over 200 miles from her home.

Concerns from the family regarding Mrs Copeman’s welfare and the distance from her beloved home county were dismissed – and Mrs Copeman was transferred on the 12th December 2019 without the opportunity to say goodbye to her husband or children.

Just four days later, Mrs Copeman was being prepped for the lengthy return journey home after tests revealed she had developed a urinary tract infection. CCTV footage showed Peggy slumped in her wheelchair and reports later revealed that a full physical examination was not completed prior to her journey as Mrs Copeman was ‘unwilling’.[1]

On 16th December, Maxine received a call to notify her that the ambulance had been forced to pull over on the motorway. Mistaking signs of respiratory distress for snoring, the staff onboard failed to notice that Mrs Copeman had become increasingly unwell, resulting in a fatal cardiac arrest.


“The staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them” (Jacqueline Lake).

Senior coroner Jacqueline Lake concluded, following a five-day inquest, that the crew onboard the Premier Rescue Ambulance Service (PRAS) had failed to provide ‘prompt medical attention’. The van did not have a stretcher or defibrillator and staff appeared unable to perform CPR correctly, with no rescue breaths administered. Ms Lake stated that this ultimately accelerated Mrs Copeman’s death.


Painting a concerning picture

Sadly, Mrs Copeman’s story is far from unusual.

A national healthcare service under strain has increased the reliance on private medical providers such as PRAS, who have recently had their license suspended by the Care Quality Commission (CQC) health watchdog. The CQC have also previously raised concerns that some patient transport services are operating ‘in a manner more like a taxi than an ambulance service’.[2]

Furthermore, the Norfolk and Suffolk Foundation Trust (NSFT), the health board responsible for Mrs Copeman’s care, has been promising ‘for almost a decade’ to end the practise of sending patients out of the area to receive treatment.[3] Yet papers made publicly available showed that the NSFT had spent almost £7m on out-of-area beds in 2019-2020.

The NSFT have been tasked with meeting the national target of zero inappropriate placement admissions by September 2021. With just months until the deadline, we hope that Peggy’s legacy will have a lasting impact in ensuring that everyone – particularly the elderly and vulnerable – are able to access effective mental health services close to their home, family and support networks.


Reflecting on the coroner’s conclusion

Despite only concluding a few days ago, the inquest has already prompted what we hope will prove to be meaningful change; the suspension of PRAS’s licence by the Care Quality Commission and the coroners recommendation to ensure the provision of Basic Life Support on-board all transportation vehicles may go some way in preventing incidents such as this. However, we are cognisant of the fact that Peggy’s story is one of thousands and there is much more work to be done. And of course, this will not bring back Maxine’s mother, nor give her the chance to say a final goodbye.


Maxine and Nick Fulcher, Peggy’s daughter and son-in-law stated:

“Although the inquest has concluded, we are left searching for answers to questions that continue to haunt us – why was Peggy sent so far from home, despite being so ill? Did they schedule breaks and provide her with food and water during such a long journey? Why is there such a disparity in behaviour between the reports given by medical staff, who insist Peggy was swearing and forceful, and the CCTV footage that shows a vulnerable, elderly woman unable to sit up in a wheelchair?

The inquest has been immensely difficult for us. To relive the events that occurred prior to Peggy’s death, to hear to the conflicting stories and witness the lack of compassion displayed by the teams we trusted to provide care for Peggy has been harrowing. However, we would like to extend our gratitude to Craig and Aimee – with their support and compassion, we never felt alone during the inquest proceedings.

We weren’t able to say our final goodbyes to a woman who doted on us all. Peggy was an amazing, kind mother and grandmother, and to know that she died on the motorway, surrounded by strangers, is heart-breaking”.


A senior caseworker at INQUEST, the charity who provided support to the family, stated:

“This is the third time this week that a jury or a Coroner returned a damning conclusion in relation to a private company whose failures resulted in the death of a vulnerable person.

The shameful failures and neglect identified in Peggy’s death are an indictment of a mental health system which deemed appropriate to place an 81 year old woman miles away from her family and sources of support.

Dangers involved in the NHS outsourcing psychiatric care of vulnerable people to private institutions is an ongoing issue and unless it is addressed urgently will inevitably result in further unnecessary deaths”.

If you feel that you or a member of your family has been treated unfairly by a public authority, please get in touch with our expert team for a free and confidential discussion on 01633 244233 or email hello@hevans.com.


[1] BBC News, ‘How a patient treated 280 miles from home died on the M11 hard shoulder’, 2021.

[2] The Independent, ‘Private ambulances increasingly used by NHS ‘putting patients at risk’, damning report finds’, 2019.

[3] Eastern Daily Press, ‘Just three months to end mental health bed scandal’, 2021.

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