Mother dies after ambulance 1 minute away is called back

By Claire Ellicott

The woman is thought to have died of heart failure soon after a nurse turned the ambulance around and ordered a GP visit instead. Photo / Getty
The woman is thought to have died of heart failure soon after a nurse turned the ambulance around and ordered a GP visit instead. Photo / Getty

A mother was found dead on her living room floor after an NHS 111 nurse cancelled an ambulance just a minute away, an inquest heard yesterday.

Ann Walters, 61, is thought to have died of heart failure soon after nurse Pete Richardson turned the ambulance around and ordered a GP visit instead.

An investigation found he had "not demonstrated an understanding of heart failure" and was "unable to pick up clues from the patient".

Yesterday, he admitted making a mistake and apologised to her family.

Mrs Walters called 111 at around 8am on December 28, 2014, asking for a doctor to visit her, and told staff she had a heart defect, the inquest heard.

But hearing how breathless she was, the call handler classified her case as an emergency and rang 999 asking for an ambulance to be sent.

A crew was dispatched from Portsmouth's Queen Alexandra Hospital to her home in the city.

However, while the paramedics were on their way, Mr Richardson, a qualified nurse and clinical support desk practitioner for the 111 service, called Mrs Walters back and then cancelled the ambulance when it was just a minute away. He told the hearing this was because during the call she was "forthright" about wanting a doctor.

The out-of-hours GP service called her an hour later, but there was no reply. Mrs Walters' lifeless body was found at 6pm, almost ten hours later, by her son, Lawrence Thorpe, a 25-year-old former teacher, who had been resting upstairs in his room that day.

A doctor turned up at 8.30pm, after her body had been taken away.

Mr Thorpe said: "Knowing there was an ambulance minutes away from my mum, I believe it could have saved her life, even if it was only for an hour so my sister Felicity could say goodbye."

The case follows the Mail's exposure of the 111 helpline, which was linked to the death of one-year-old William Mead from sepsis after call handlers failed to realise that he was seriously ill. 

NHS 111 was introduced for patients who need medical help but are not a 999 emergency. It replaced the NHS Direct helpline, run by medically qualified staff.

Yesterday, explaining his decision, Mr Richardson told the hearing: "She sounded forthright in a way that told me, 'No means no'."

He added: "I thought I was complying with her wishes."

Portsmouth Coroner's Court heard that he was suspended following a review and retrained before returning to work last March.

Mrs Walters had a hole in her heart that would make her turn blue as her body was starved of oxygen. In her first call to 111, she told call handlers: "I just want a doctor to come out and see me."

She said she had a chest infection and could not breathe, but agreed to an ambulance being sent.

One was dispatched at 8.19am, but was turned away at 8.25am just a minute from her home.

Mr Richardson told the inquest: "During my conversation I established she was conscious and breathing and expressed a wish to be seen by a doctor and not an ambulance. I gave her advice that if her symptoms changed or got worse or if there were any concerns in the meantime to call us back straight away on 999." He also told how Mrs Walters had refused to wake her son. After ending the call, he passed the incident to the out-of-hours GP service and requested a call back within an hour. Mr Thorpe asked him:
"In hindsight, do you believe your decision was wrong?' The nurse said: "Yes." The inquest heard that calls to the out-of-hours GP service were up 30 per cent on the previous year for the Christmas weekend.

Consultant cardiologist Dr Philip Strike, of Queen Alexandra Hospital, said Mrs Walters declined an operation in 2007 to alleviate her condition, despite knowing the decision would lead to her death.

Shortly before she died, he had given her less than a year to live, and said she was at "phenomenally high risk of sudden death".

He said it was "unlikely" an ambulance or GP could have saved her.

Senior Coroner David Horsley recorded a narrative conclusion, ruling that Mrs Walters died of congestive cardiac failure. He said there was a 'strong possibility' that she died between her phone call with Mr Richardson and a call from the out-of-hours GP an hour later.

Luci Stephens, of South Central Ambulance Service, which runs the local 111 line, said: "We would like to say how sorry we are. The trust has undertaken an extensive investigation in consultation with the family, and has introduced stringent changes to its 999 clinical support desk procedures."

-Daily Mail

- Daily Mail

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