Blunders let student die waiting for ambulance
A UNiVeRSiTY student died of a ruptured spleen after waiting almost 90 minutes for paramedics during a catalogue of failings from an ‘under pressure’ ambulance service, an inquest heard.
kathryn Richmond was repeatedly denied help as up to six out of 13 ambulance crews were on breaks as she fought for breath – while her parents’ 999 calls were twice wrongly downgraded.
A coroner heard that the clinician on duty at the South West Ambulance Service control room – who downgraded the second call – had felt pressured not to grade too many calls as ‘red’, requiring immediate response, because the service was struggling to meet response times.
When Miss Richmond, 20, finally made it to hospital she went into cardiac arrest and died, just over six hours after the first 999 call was made. her parents, Alan, 54, and Jacqueline, 52, both company directors, were told that had their daughter received treatment before going into cardiac arrest, she would probably have survived.
Miss Richmond, from Poole, Dorset, suffered a ruptured spleen due to a rare complication from glandular fever and collapsed at home at midnight on April 21, 2015. her parents dialled 999 at 12.14am and an ambulance was despatched which should have reached her within eight minutes.
But as the call continued, call handler Tanya Javadi changed the grading from Red 2 to Green 2 and the ambulance was diverted.
At that time four of the 13 ambulance crews in the area were on one-hour breaks, having been on duty for more than five hours. When the Richmonds called again at 12.40am their daughter was relisted as a Red 2 case, but the nearest crew not on a break were 25 minutes away.
That vehicle was sent, only to be diverted when Duncan Smith, the clinical supervisor in the Dorset control room, downgraded the call for a second time. Asked by coroner Rachael Griffin if he felt under pressure to downgrade Miss Richmond’s call, Mr Smith said: ‘Yes, there is some pressure, more so in the Dorset hub because the dispatchers would be sat 2ft in front of me, looking at me, asking if that call is going to be red.’ Mr Smith said he had ‘fixated’ on an assumption that asthmatic Miss Richmond was hyperventilating, when further probing would have revealed she was in hypovolemic shock due to blood loss. Nicholas McGuinness, the senior dispatcher that night, told the inquest the amount of available resources were ‘far lower’ than was needed ‘to safely deal with the amount of calls we receive’.
The Bournemouth hearing was told that when control room staff called the Richmonds at 1.31am, six out of 13 crews were on breaks. Paramedics finally arrived at 1.39am – 85 minutes after the first call. They realised Miss Richmond, who was studying Tourism Management at Bournemouth University, needed immediate hospital care. But she died at 6.22am.
Paul Durden, a consultant general surgeon who reviewed the case, said: ‘Any surgical or medical intervention that could prevent cardiac arrest probably would have led to the operation (to remove spleen) being successful and kathryn surviving.’
Dr Andy Smith, SWAS medical director, told the hearing that paramedics’ rotas had been overhauled. Recording a narrative verdict on Wednesday, Mrs Griffin said cause of death was natural – through the glandular fever – but the ‘delay in receiving necessary lifesaving treatment’ was a contributory factor.
‘Intervention could have saved Kathryn’