A child died after an ambulance took an hour to reach her at a practice in Cardiff, despite the GP requesting paramedics arrive within eight minutes, an inquest has been told.
GP Dr Nicola Leeson called for the ambulance at Rumney Primary Care Centre after becoming concerned the 12-year-old girl, Ffion Jones, was dehydrated when she came into the surgery on December 7, 2016.
But before the paramedics arrived, Ffion – who was later diagnosed with Addinson’s Disease, a rare disorder of the adrenal glands – went into cardiac arrest. She failed to regain consciousness and died in hospital the next day.
The inquest at Pontypridd Coroner’s Court, first reported in Wales Online, heard that Dr Leeson said she requested the eight-minute ambulance – reserved for the highest category of incidents – by calling an emergency phone number for healthcare professionals, as per recent training.
However, she said she was told by the operator it was not possible to send an eight-minute ambulance, but would try calling 999 instead.
Dr Leeson said she had rung the phone number designated for healthcare professionals first, because in training she had been told 999 calls would not send an eight-minute ambulance unless it was for a cardiac arrest, choking or hanging incident.
The Welsh Ambulance Service Trust said an audit of the call found the operator should have escalated the situation when Dr Leeson challenged the operator’s decision that the incident was not categorised as the highest priority.
WAST’s interim area manager for emergency medical services Kate Blackmore told the court: ‘Although the categorisation was deemed appropriate based on the questions and answers, they felt the customer service provided to the GP was inappropriate.
‘The doctor had advised that she wanted to escalate the call. The call handler advised that that couldn’t be done.’
While waiting for the ambulance, Ffion collapsed and Dr Leeson put in another ambulance call – this time for cardiac arrest – and the call handler asked for the incident to be verified.
Dr Leeson said: ‘Just as we were applying the oxygen another receptionist appeared to say that I had to go and confirm it was a real cardiac arrest before the ambulance service would send an ambulance.’
When a paramedic finally arrived, cardiac arrest was confirmed and CPR started. Ten minutes later an ambulance took Ffion to University Hospital Wales.
Coroner David Regan said Ffion’s cause of death was hypoxic brain injury, out of hospital cardiac arrest and Addisonian crisis.
He 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’.
The family’s solicitor said it was likely damages would be pursued.
Meanwhile, GPs have previously said under-pressure ambulance services are delaying their arrival due to the mistaken belief that patients are safe if a doctor is present.