Ambulance service staff have apologised to the family of a woman who died after waiting for an ambulance for 50 minutes while struggling to breathe.
Trudy Jones, 49, of Tan Y Dre, Rhosnesni, Wrexham, died at her home on January 3, 2016, an inquest was told yesterday.
A post-mortem examination was carried out by Dr Mark Lord, an independent pathologist.
Nicola Jones, assistant coroner for North Wales East and Central, confirmed the cause of death was not a heart attack but heart failure as a result of a previous heart attack.
At the hearing at Ruthin, Ronald Jones, Mrs Jones’ husband of 15 years, said he called 999 at about 11.30pm on January 2 as his wife was “unwell and had increased shortness of breath”.
Jaqueline Rowlands, a clinician at Wrexham Maelor Hospital, later called to assess Mrs Jones who was struggling to speak, which was when Mr Jones assumed an ambulance was en route.
Ten minutes after the call was received, at about 12.10am, Mr Jones had to call 999 again as his wife was in “great pain”.
Just before 12.15am she collapsed and stopped breathing and a third call was made to the ambulance service.
Mr Jones and his son Stephen Jones were told how to conduct CPR until the paramedics arrived.
In his statement Mr Jones Snr asked for the ambulance crew and staff involved to be called to the inquest.
Mr Jones voiced his concerns as the family were told the ambulance was “coming as quickly as possible” but they were not given any indication of when Mrs Jones would receive medical attention.
Mrs Rowlands said the hospital had handover delays at the time.
She admitted she had wrongly categorised Mrs Jones as ‘amber 2’ rather than ‘amber 1’ as “the patient was unable to complete sentences” and the effort required for her to breathe “had the potential to worsen”.
The clinician apologised for her actions and had since formulated a ‘learning plan’ with colleagues as “elements needed to be addressed”.
Jill Plemming, head of control for the Welsh Ambulance Service Trust (WAST), told Mrs Jones’ family that on this occasion the service had “got it wrong” and all calls had been audited since the death.
Ms Plemming said Mrs Jones should have been “amber 1 from the beginning” but when answering on the computer a question of whether Mrs Jones was able to talk, the call taker had “clicked yes instead of no” which Ms Plemming described as being down to “human error on a very challenging night shift”.
She said call takers were now asked to “empower families to make decisions”, especially when waiting times are high. And those involved had been given further training.
The assistant coroner said Mrs Jones had not died in vain and that the changes being made after her death would “save people’s lives”.
Ms Plemming, addressing the family, added: “The last thing we want to do is to let patients down.
“I will apologise on behalf of all of us.”
Jonathan Cross, a paramedic for WAST, was working at Dobshill near Buckley before being called to attend Mrs Jones’ home with fellow paramedic Dave Carter.
He confirmed there was “no cardiac output” when they arrived at 12.20am and despite all attempts of assisted life support being carried out, a joint decision was made to stop procedures as Mrs Jones was showing no changes in her condition after 20 minutes.
She was pronounced dead at 12.45am.
It was revealed at the inquest that around the time Mr Jones first called an ambulance a ‘red’ level call came in which involved a child, when the service was already experiencing a high volume of calls.
Dewi Lloyd also confirmed they received 360 calls on the night of January 2.
Assistant coroner Mrs Jones said the ambulance response times were high in relation to patient flow at Wrexham Maelor Hospital and Glan Clwyd Hospital at Bodelwyddan.
Jillian Harrison, lead manager at Wrexham Maelor, confirmed the longest wait for a patient on the evening of January 2, 2016 was 21 hours and some had to wait six hours outside the hospital after being taken in an ambulance.
Betsi Cadwaladr University Health Board Nigel Lee senior manager said there was “major pressure” on hospitals that evening and the emergency departments are often “in high demand”.
He also confirmed 19 patients were waiting for beds in the early hours of January 3.
The inquest was adjourned and will continue today at 10am.
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