Inquest hears ambulance call-handler made wrong decision
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Version 0 of 1. A call-handler who stood down an ambulance a minute away from the home of a dying woman has told an inquest that he made the wrong decision. An inquest into the death of Ann Walters found significant failings in the 111 call-handling on the day of her death and a coroner ruled that the actions that were taken “fell below the standards” set by the ambulance service. But the coroner David Horsley said it was unlikely she could have been saved by the paramedics. He heard that, on the morning of her death, Walters called 111 complaining of breathlessness. An ambulance was dispatched, then stood down. The call had been passed to the 999 service but it was intercepted and transferred to the out-of-hours doctor service by a clinician on the desk. The call-handler, triage nurse Peter Richardson of South Central Ambulance Service, said he stood down the ambulance after Walters said she wanted to be seen by a doctor, rather than by a paramedic. “At 8:19am I called Ann Walters using a contact telephone number on my computer screen which had been passed over from the 111 service,” Richardson told Walters’ son, Lawrence Thorpe, at the inquest into his mother’s death on Thursday. “There was no reply. I called back two more times and she picked up. She was conscious and breathing and expressed [that] she wanted to be seen by a doctor, not an ambulance. “I noticed she was short of breath and passed details back for a one hour call-back, and told her to call 999 if her symptoms changed or got any worse. I stood down the ambulance and reassured her the out-of-hours doctor would call her back within an hour. She said she wanted a doctor because she thought she had a chest infection. Her symptoms were similar to those she had when she had a previous infection.” Walters, who was 61 when she died, suffered from a large hole in her heart and was found dead by her son shortly before 6pm on 28 December 2014 – 10 hours after she had called the emergency services. Horsley said that Walters died alone “in all probability, before the first out-of-hours call was made”. Recording a narrative verdict, the coroner said: “For me the irony of this is the precise minute the ambulance was stood down it was only about one minute from Ann Walters’ home. Had the paramedics got to her in time it was not likely that there was anything they could have done to save her. Assistance might have eased her passing and it was so near to her, but I can comment no further.” The coroner heard that Walters, who was from Portsmouth in Hampshire, declined life-saving open-heart surgery years earlier because she wanted to see her son graduate university. As her condition deteriorated the hole became larger and she spoke with consultant cardiologist Dr Phillip Strike about surgical options. But by this point, it was too late. She was estimated to have weeks or months left to live before her death. Lucy Stephens, of South Central ambulance service, said an assessment of the call handling that day deemed it to be “inadequate”. As a result Richardson was suspended from telephone duties and an action plan put in place regarding the competence of telephone triage. Speaking after the inquest, Thorpe said he was pleased the coroner gave a narrative conclusion rather than a “death by natural causes”. He added that hearing Richardson’s admission was comforting. |