Four 999 calls before ambulance was sent to dying dad
SERVICE ‘DEEPLY REGRETFUL’ OVER MISTAKES
THE family of a dying father had to telephone for an ambulance four times before one was sent out to them, an inquest has heard.
Derby man David Bown was left waiting nearly half an hour longer than he should have been for medical help after being taken ill with a heart problem.
Derby Coroner’s Court was told the 52-year-old had been with his parents in Woodlands Road, Allestree, when he was having trouble breathing on Friday, August 16, 2019.
An inquest into his death was told that his family had called for an ambulance three times but none were dispatched because the calls were incorrectly categorised as being less serious by the handlers.
It was only when the family called a fourth time that a call handler assigned Mr Bown as being a top priority patient and an ambulance was sent to him, although it would later be revealed that this delay did not have an effect on his death.
At the inquest a member of East Midlands Ambulance Service (EMAS) apologised to Mr Bown’s family and said changes had been made to ensure it did not happen again.
Mr Bown, who worked as a mechanic, had originally complained about having intermittent chest pain in the weeks leading up to his death.
Susan Jevons, senior quality manager at EMAS, told the inquest that it had received the initial call from Mr Bown’s family at 6.05pm on the Friday evening.
She said the call handler, who was using a dispatch system which categorises calls based on how serious they are, incorrectly placed him in Category 2, which gives it the secondhighest priority when sending out response vehicles.
Mr Bown’s breathing was irregular, something she said the call handler should have picked up on as a sign of cardiac or respiratory arrest and escalated to Category 1, which would have immediately dispatched a paramedic to him.
She said this oversight happened again on two other calls made by the family at 6.15pm and 6.23pm, which were picked up by two other call handlers, before it was categorised correctly during the fourth and final call at 6.32pm.
An ambulance finally arrived at 6.41pm, 36 minutes after the initial call and the crew began CPR on Mr Bown, who was no longer breathing. However, he could not be revived and he died that evening.
Ms Jevons said an investigation was carried out following the evening’s events, and all four call handlers were spoken to.
“From talking to the dispatchers and listening to the calls, I don’t think they heard or were listening as they are taught to listen,” she said.
Ms Jevons said since then all call handlers – apart from 19 who have been shielding – have undergone mandatory training workshops to ensure it does not happen again.
She said: “Of the four EMDs (emergency medical dispatchers)we only have two in the trust – two have left, not due to this incident.
“They [the two still at the trust] often talk about where they went wrong to new EMDs.” The inquest heard that there had not been a delay in any other part of EMAS’s response, and that medics were available to go out immediately had the call been categorised correctly.
“It was an awful experience,” Ms Jevons said.
“I’ve met with the family and I cannot apologise enough for how we dealt with those calls.”
A post-mortem report later revealed Mr Bown had scar tissue on his heart after part of the muscle died, something that was attributed to a heart attack caused by a blood clot in the week prior to his death.
On the day of the incident, this scar tissue tore apart, causing a devastating bleed from his heart into the space surrounding it. This increased the pressure on the heart, causing it to stop.
Dr David Kirby, a consultant in emergency medicine at Luton and Dunstable Hospital, said the bleed was “sudden and catastrophic” and that even if an ambulance had been sent on time Mr Bown would have still died.
“Had they [an ambulance] got there sooner would that particular patient had a different outcome?” he said. “The answer is no, to put it bluntly.
“Even if the ambulance had arrived one in one minute I do not think the outcome would have been any different.”
Dr Kirby said the only treatment for Mr Bown would have been to operate on him to relieve the pressure caused by the blood and surgically repair the hole in the heart.
He added that Mr Bown, of Blenheim Parade, would have had to be taken to Glenfield Hospital in Leicester or Royal Stoke Hospital to have this done, something that would have taken too long.
“It’s a catastrophic situation,” he said.
“It’s that need for surgical repair and that being the only treatment that makes me certain there’s no way he could have been transported to a site capable of providing that for him in a state fit enough for him to have it.
“The total time elapsed then would have been an hour and a half. There’s no way that Mr Bown would have survived that long.”
Coroner Tanyka Rawden recorded Mr Bown’s cause of death as a ruptured heart, caused by the splitting of scar tissue left over from a heart attack.
Following last week’s inquest, Richard Henderson, CEO of EMAS, said: “I would like to offer my deepest condolences to Mr Bown’s family, all of whom we understand have faced a deeply difficult and emotional time.
“We fully accept the coroner’s findings and conclusions, and we accept that the service provided to Mr Bown was not to the standard he rightly expected.
“We recognise in the coroner’s conclusion that although earlier arrival would not have altered the tragic outcome for Mr Bown, the delayed attendance caused by incorrect categorisation should not have occurred and for this, we are deeply regretful.
“We have urgently reviewed the areas of learning which have been identified by our own internal investigation.
“Our Emergency Medical Dispatchers have undergone reflective learning and additional training on ineffective breathing within EMAS to prevent this from happening again, and this additional training is also now mandatory for all new recruits to the role and regular audits now take place.
“We know this comes too late for Mr Bown and his family and deeply regret this.”
I’ve met with the family and I cannot apologise enough for how we dealt with those calls. Susan Jevons