• 78 year-old Diana Gudgeon’s death could have been prevented with more prompt treatment, Northampton coroner rules.
  • East Midlands Ambulance Service was six double crewed ambulances and four fast response vehicles short on the shift. 
  • Coroner reports concerns about 111 and EMAS triaging of sepsis cases 

A patient died after waiting over eight hours while the East Midlands Ambulance Service struggled with a severe shortage of response vehicles.

EMAS has been warned by assistant coroner for Northampton Hassan Shah there is a risk future deaths could occur unless action is taken.

Mr Shah concluded that prompt treatment could have prevented the death of 78-year-old Diana Gudgeon on 25 May 2018.

Ms Gudgeon was diagnosed by her GP with a urinary tract infection on 21 May 2018, some time after which she collapsed at home and remained lying on the floor “for a prolonged time”. On 22 May a call was passed from the non-emergency 111 service to EMAS and although Mrs Gudgeon had signs of central nervous system and neurological problems, which required an urgent response, the call was given a category three 120-minute response.

Despite a call with a nurse later that evening Mrs Gudgeon’s case was not escalated and no treatment other than oxygen was given by a solo responder, who arrived at 4.50am on 23 May.

As many as 8.5 hours after the initial call a double crewed ambulance arrived and it was determined Mrs Gudgeon’s “abnormal vital signs” were due to infection and sepsis. After being taken to Northampton Hospital she died two days later.

According to Mr Shah’s regulation 28 report, the consultant in intensive care and anaesthesia said: “If antibiotics were given earlier, the severity of multi-organ failure that occurs in septic shock may have been less.”

EMAS said it was six double crewed ambulances and four fast response vehicles short on the shift, which had a “significant impact on service”.

Other concerns cited by the coroner were:

  • 111 and the EMAS call handling system did not regard Mrs Gudgeon’s symptoms as needing an urgent response, despite the risk of sepsis.
  • It was suggested in evidence that if the same facts were put into the 999 triage system they would likely allocate a higher priority call than through 111.
  • Despite EMAS having a capacity management and escalation plan (CMP), this did not trigger the deployment of additional ambulances.

In his response to the coroner’s report, chief executive of EMAS Richard Henderson said on this occasion it was not possible to move resources from one division to another and since the incident the trust had “been through a rigorous governance process”.

Mr Henderson said each call received by the trust is now either triaged via the advanced medical priority dispatch system or the 111 system and at the time there was no information provided by the caller that warranted an escalation.

Paul Benton, EMAS acting director of quality, said the ambulance trust had invited the coroner to visit the emergency operations centre to “allow us to demonstrate the systems and processes in place”.

“We will also evidence the improvements made to patient services following significant additional investment announced by our commissioners in 2018 (£9million), and the subsequent recruitment and purchase of new and additional ambulance vehicles,” he said.

Mr Benton added: “Our plan is to recruit frontline staff during 2019-2020 which will help us to continue to improve patient services. We know this comes too late for Mrs Gudgeon and her family, and deeply regret this.”