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Schoolgirl died from heart attack after hour wait for ambulance at GP practice

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 Addison’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 Onlineheard 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.

Earlier this year, a major Pulse investigation revealed that patients in need of an ambulance at a GP surgery are routinely facing waits twice as long as patients who call 999 from elsewhere

This prompted LMC delegates at the UK LMCs conference in Belfast to overwhelmingly vote for the BMA's GP Committee to tackle the issue, which they called 'detrimental to patient care'.

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.

Readers' comments (21)

  • Vinci Ho

    Obviously we have not had all the details of this tragedy. But reality is this kind of following the protocols, triaging , category of urgency and eventually conclusion by algorithms, is an overcompensation for a system being neglected too long by successive government(s) . The end result is painted by loss of lives . One can say we are crybabies, scaremongers etc but the reality has become too apparent to be denied by this bunch of politicians . I always believe that we , doctors, always have a duty to oversee these despicable politicians and bureaucrats from harming our patients but the truth is we have only limited power to prevent disasters from happening.....,.......

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  • These are the type of headlines that puts off people from working in the NHS - why is PULSE turning into the daily nutter?

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  • This is a real issue

    Ambulance Call Centres downgrade the urgency of Blue light calls if they are from a GP Practice.

    The GPC needs to raise this as national issue.

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  • Absolutely unacceptable.

    Any care pathway in which a call handler can overrule the opinion of a trained clinician at the side of the patient risks this happening.

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  • I went on a BLS course yesterday. We spent 15 minutes discussing how to ensure we get ambulances in the necessary time frames for emergencies. sign of the times.....

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  • Not surprised the ambulances downgrade the call just because the patient is at a GP's surgery. If they need a hospital, they need a hospital. Not a GP surgery. GPs in the UK are well and truly abused leading to tragedies like this. Still the best care in the world?

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  • Awful for the family of this child and the staff involved also.

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  • A very sad case but for me the most chilling aspect is the non speak bureaucratic semi disowning ".....they felt the customer service provided to the GP was inappropriate."

    "Customer service"- to what depths have we descended?

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  • I waited 1 hour 40 minutes for a suspected myocardial infarction (not an arrest) recently. Perhaps GPs should be provided with green lights to go on their cars and simply drive casualties straight to hospital. You are tied up with these patients till the ambulance arrives anyway. I don't imagine there would be any more deaths en route than there are from delayed ambulances.

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  • “Customer service”? Are GPs now “customers” when they ring for an ambulance?

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  • Nhsfatcat

    Where is the logic? A qualified GP thinks a blue light response is needed- shred the fucking protocol and JFDI!

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  • the OOH is becoming dangerously poor. It is not only the ambulances that are failing but the emergency doctors are too thin on the ground. And yet you can been seen by a doctor in 'the hub' for a sniffle.
    we need to get rid of the hub so there is enough money and doctor numbers to provide a safe emergency service at weekends.

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  • Addison’s, not Addinson’s

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  • DrRubbishBin

    the use of the phrase 'customer service' in a nut shell encompasses all you need to know

    people embedded in a "model" who can't see outside the box (and don't even know they are in one)

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  • This is awful for all the reasons cited.Addisons if it was truly autoimmune in this case is one condition which often niggles subacutely with vague but recurrently presenting symptoms, and should always be somewhere in the clinicians mind as a possible differential in recurrent attenders.

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  • I cannot believe the Ambulance service said 'customer service'!
    Clearly it is not safe for patients to be ill at a GP surgery - they must be directed elsewhere.

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  • soul destroying for the family and for the doctors. so sad. condolences to the family and the practice.

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  • @ Nostradamus horoscopes. How do we build resilience to cope with, or better, to avoid this sort of cluster-f*** without (a) being made aware and (b) discussing and (c) creating coping/battle strategies??
    It's no use your acting like an ostrich in your big, shiny building, where 'activity', (not outcomes) determines funding!

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  • I ma not a customer requiring service... the patient, shortly as here to be an ex-patient, is.

    I am amazed these stories are not more common: we teach receptionists to say no doctor is present if calling ambulance.

    My sympathies to all concerned.

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  • I am used to being frustrated by the mainstream media mixing up heart attack (myocardial infarction) with cardiac arrest - could Pulse please try to get it right?

    Unfortunately ambulance service protocols seem to allow "doctor in attendance" to be used to tick the "8-minute response achieved" box so calls are treated with less priority than regular 999 calls. They also seem to think that any doctor automatically comes with an AED, emergency drugs and up-to-date resus training even when pushing their trolley round a supermarket.

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