Seaford woman who died after ambulance wait ‘failed’ by system, coroner rules
A 90-year-old Seaford woman who was pronounced dead after waiting almost two hours for an ambulance was ‘failed’ by a system under huge pressure to be as efficient as possible, a coroner has ruled.
The apparent late arrival of ambulances was linked to the deaths of three pensioners in East Sussex in 2017.
Daisy Filby, 90, waited for about an hour and 45 minutes for an ambulance as she lay face down, unable to move, at her home in Seaford after a fall, an inquest in Hastings heard.
She died as the result of an ‘accident contributed to by neglect’, senior coroner Alan Craze said on Wednesday.
Her disabled daughter Linda Filby was unable to lift her and kept ringing 999. The first 999 call was made on June 19, 2017, at 8.42, the last call was made at 10.11 and the ambulance arrived at 10.24. Mrs Filby was pronounced dead when paramedics arrived.
“There clearly was a failure to provide basic medical attention,” the coroner said, adding: “It’s a very tragic case indeed.”
Mr Craze said the problem in this case was not the actions of any one individual, adding: “The problem ultimately is systemic and the heart of it is the call-taking and decision-making system.”
He said it is ‘easy’ for him to see what probably happened – that in a period of austerity, pressure has been ‘huge’ to use available resources as efficiently as possible.
Mr Craze referred to the programming of a computer to make decisions, and said that in the case of Mrs Filby ‘only a properly-trained human being’ could have listened to the call and made decisions.
He said there was ‘no meeting of minds’ between the caller and the call-taker.
“The tragedy is that there was no proper dialogue on any of those first four calls,” the coroner said.
He said the system used by South East Coast Ambulance Service appears to be a nationally rolled-out system and added: “That system has failed Mrs Filby and her daughter.”
Mr Craze said the cause of Mrs Filby’s death was postural hypoxia and hypertensive heart disease.
Meanwhile, the coroner described the death of Anthony Harding, 84, as a ‘very sad case’.
Mr Craze concluded that Mr Harding died of natural causes following a 999 call after he collapsed.
The call was triaged as a ‘minor medical issue’ and medics did not arrive for more than an hour ‘because of a shortage of resources’, the coroner said.
He said the issue here was the fact, which he said was not denied, of the late response and arrival by the ambulance.
The inquest heard that Mr Harding’s wife called 999 at 6.32pm after he collapsed on August 21 2017, and an ambulance technician arrived at 7.45pm.
He found Mr Harding lying on his back in a bathroom but noted his airway was clear and he was able to talk. However, he then had a seizure and was sick.
Paramedics arrived to assist at 8.31pm after the technician requested ‘red crew back-up’.
The inquest heard Mr Harding was pronounced dead at 10.34pm, and cause of death was given as ruptured abdominal aortic aneurysm.
The coroner later also ruled that great-grandfather Maurice Goodwin, 87, died on August 31, 2017, from natural causes contributed to by neglect.
The inquest heard Mr Goodwin was discharged from hospital that day and he returned home, but soon complained of discomfort.
His family discovered that his trousers were soaked in a lot of blood from his catheter, which was also full of blood.
Mr Goodwin’s wife of 64 years, Barbara, called 999 at 5.52pm but was told an ambulance would not be coming, and her husband had been referred to the community team.
Concerned for her husband as time went on and nobody arrived, she kept calling 999.
Mr Craze said that the call-takers were told Mr Goodwin was bleeding, but they passed on to other matters, such as questions about whether he had any sores or blisters.
District nurses arrived at 9.05pm, more than three hours after the first 999 call.
“They said it was too late and he had died,” Mrs Goodwin previously said.
“There is no doubt in our minds that his pain and distress was a contributing factor to his death.”
She told the inquest she wanted to know ‘why the ambulance service failed to attend what was clearly an emergency situation’.
“I wish more than anything that he hadn’t had to die like this.”
The cause of Mr Goodwin’s death was given as an exacerbation of chronic obstructive pulmonary disease (COPD) and ischemic heart disease.
High blood pressure and blood loss also contributed, the coroner said.
Mr Craze said the problem in these cases seemed to be the call-answering service.
“It seems quite clear to me that in 2017 it was not fit for purpose,” he added.
A spokesman from South East Coast Ambulance Service (SECAmb) said: “Our thoughts are with the families and everyone affected at this difficult time and we are very sorry for the service they received.
“We have listened very closely to the coroner throughout and we are committed to making further improvements where necessary.
“Since these incidents took place in 2017, it is important to note that a significant amount of work has taken place to improve the service we provide, both in our emergency operations centres and in responding to patients in the community.
“Many of these improvements were highlighted in our most recent Care Quality Commission report.
“We are continuing to work hard so that we are best placed to respond to patients across our region and we remain committed to further improvement.”