FFION’S DEATH SPARKS CALL FOR ACTION
A CORONER has warned that “further deaths will occur” unless action is taken to address the failures by the Welsh Ambulance Service which resulted in the death of a 12-year-old girl.
Ffion Jones, from Rumney in Cardiff, collapsed at her local doctor’s surgery where she was taken after complaining of tiredness that led to severe vomiting on December 7, 2016.
Ffion’s GP tried to request an eightminute response ambulance, but by the time paramedics arrived an hour later she had gone into cardiac arrest and later died in hospital.
An inquest in September found Ffion died of a crisis of undiagnosed Addison’s disease – a rare disorder of the adrenal glands.
Assistant Coroner David Regan found that a delay to escalate Ffion’s case by a Welsh Ambulance call handler was “causative” of her death, and if it had been escalated it is “likely that she would have survived”.
After recording a narrative conclusion, Mr Regan has now sent his concerns to the chief executive of the Welsh Ambulance Service.
These have been included in what is called a Regulation 28 report which is intended to help prevent future deaths.
The report reads: “Ffion Jones died as a result of a crisis of Addison’s disease following a collapse at the surgery of her general practitioner.
“Despite requests for urgent attendance, there was no ambulance attendance for almost one hour following her general practitioner’s emergency call.
“The call was not escalated to the clinical support desk as it should have been.
“Escalation would have been likely to have led to ambulance attendance prior to Ffion arresting, in which case Ffion would have been resuscitated and quickly transferred to hospital. It is likely that she would have survived.”
During the inquest, GP Dr Nicola Leeson told the court Ffion and her mother Stephanie arrived at Rumney Primary Care Centre at about 2pm on December 7, 2016.
Dr Leeson said she became concerned Ffion’s vomiting may have caused her to become dehydrated, and under examination found her breathing was elevated, her heart rate was about 160 beats per minute, and her blood pressure was so low it was not possible to take a reading.
She said she spoke to a 999 operator and requested an emergency eightminute ambulance.
But the call was instead given a lower priority rating, and ambulance staff didn’t arrive until an hour later.
In the report, Mr Regan said an improvement plan provided by the
Welsh Ambulance Service at the inquest did not include any “consideration of the specific shortcomings” which led to Ffion’s death and there is still “no dedicated means” for external health care professionals to elevate the urgency of calls.
Mr Regan wrote: “There is a real risk of the recurrence of the circumstances leading to Ffion’s death.
“In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”
The report has been sent to the Welsh Ambulance Service which is required to respond with details of action that is proposed or has been taken.
A copy of the report has also been sent to Ffion’s family, the Health Inspectorate Wales, the Welsh Government, and the medical director of Cardiff and Vale University Health Board.
A spokesperson for the Welsh Ambulance Services NHS Trust said: “We submitted our response to the coroner last week, and this is now being reviewed by his office.
“It would be inappropriate for us to comment further at this time except to say that our thoughts and deepest sympathies remain with Mr and Mrs Jones and their family.”