Dad tells of family’s grief after inquest into daughter’s death
A DAD has spoken about his family’s struggle to cope with the loss of their “generous, funny, bubbly little girl” after an inquest heard an emergency services call handler failed to escalate an ambulance request before she died.
Ffion Jones, from Rumney, was left waiting for more than an hour after her GP attempted to call for a priority ambulance to take her to hospital.
The 12-year-old had gone to the GP surgery that afternoon with her mother Stephanie and was found to have an elevated heart rate, fast breathing and her blood pressure was so low it was unreadable.
She was pale, had been vomiting for the past 48 hours and her GP was concerned she may be dehydrated.
By the time the ambulance arrived an hour later, she had gone into cardiac arrest.
Although she regained a pulse on her way to hospital, she was declared brain stem dead the following day on December 8, 2016.
An inquest into her death held at Pontypridd Coroner’s Court heard on Thursday that doctors at the University Hospital of Wales, Cardiff, quickly established Ffion was suffering from hypovolemia and shock related to undiagnosed Addison’s disease – a rare disorder of the adrenal glands.
Dr Nicola Leeson, of Rumney Surgery, examined Ffion at about 2pm on December 7 and called for an emergency ambulance.
She told the court she had tried to request an eight-minute ambulance, but was informed one couldn’t be provided.
Dr Leeson said she made her first call to 999 at 2.27pm.
A first responder didn’t arrive until 3.21pm, by which time Ffion has gone into cardiac arrest.
An ambulance arrived at 3.30pm. Giving evidence yesterday, interim area manager for emergency medical services at the Welsh Ambulance Service Trust Kate Blackmore told the court the ambulance request was given an Amber Two priority rating.
As the GP disagreed with the priority rating, she said it should have been referred to the clinical support desk who could have raised it to Amber One or Red – the most urgent.
“An audit was undertaken for the 999 call in question,” Ms Blackmore said.
“It identified that although the categorisation was deemed appropriate based on the questions and answers, they felt the customer service provided to the GP was inappropriate.
“They have given incorrect advice when the GP attempted to escalate the priority response and they didn’t show empathy towards the GP who was demonstrating anguish at the emergency situation.”
She added: “The doctor had advised that she wanted to escalate the call.
“The call handler advised that couldn’t be done.
“However, guidance had been issued that advised that in circumstances where the GP didn’t agree with the prioritisation of the incident, it should be escalated to a clinical support desk clinician.”
Ms Blackmore said an ambulance could have been made available at 2.45pm if the incident had been upgraded to Amber One before that time.
Susan Tuckett is the national clinical operations manager for the Welsh Ambulance Service Trust’s clinical contact centres.
She told the court she has experience working on the clinical support desk.
She said she believed if Dr Leeson had managed to speak with a clinician on the support desk, the incident would have been escalated.
“I think if this was me, red calls are for immediately life-threatening incidents and I think it’s hard to say without knowing the answer to questions [that the GP would have given],” Ms Tuckett said.
“I would have thought this was an Amber One.”
Coroner David Regan recorded Ffion’s cause of death as hypoxic brain injury, out of hospital cardiac arrest and Addisonian crisis.
Summing up his findings, Mr Regan said the delay to escalate Ffion’s case by the call handler was “causative” of her death, and if it had been escalated “it is likely she would have survived”. He recorded a narrative conclusion. Mr Regan said: “Ffion died as a result of an Addisonian crisis, suffering a seriously damaging arrest at her general practitioner’s surgery while waiting almost one hour for ambulance service assistance that had been requested urgently but delayed by a failure to escalate her case to the clinical support desk.”
Mr Regan added a Regulation 28 report would be made to the Welsh Ambulance Service Trust.
Speaking outside the court, Ffion’s dad Anthony gave an emotional statement alongside her mother Stephanie.
“We would like to thank HM Coroner David Regan for his thorough investigation of Ffion’s death,” Mr Jones said.
“We remain devastated by the events of December 2016 when we lost our precious daughter.
“Ffion was a generous, funny, bubbly little girl and was a pillar of our family.
“We miss her so much and struggle to cope with her loss.
“We entirely accept the conclusions of the coroner.
“Our family have the utmost respect for the frontline staff of the Welsh Ambulance Trust and nurses and doctors at UHW.
“We hope that important lessons have been learned and that no family has to suffer as a result of system failures.”
The family’s solicitor Spencer Collier said: “We will now review the findings and decide upon our next steps, but it is likely that proceedings for damages will now be issued.”