NO AMBULANCES were available to help a woman who was struggling to breathe because they were all either responding to other calls or stuck waiting at hospitals, an inquest heard.
Trudy Jones, 49, of Tan Y Dre, Rhosnesni, Wrexham, died at her home on Sunday, January 3 2016. A two-day inquest into her death began in Ruthin on Monday.
The first day’s hearing was told Ronald Jones, Mrs Jones’ husband of 15 years, called 999 at about 11.30pm on January 2 as his wife was “unwell and had increased shortness of breath” following which Jaqueline Rowlands, a clinician at Wrexham Maelor Hospital, called to assess Mrs Jones, who was struggling to speak.
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”, the inquest heard.
Just before 12.15am she collapsed and stopped breathing and a third call was made to the ambulance service.
During the second day of the inquest, Nicola Jones, assistant coroner for North Wales East and Central, heard evidence about the challenges facing the Welsh Ambulance Service Trust (WAST) and the hospitals across North Wales that weekend, as well as how these factors had affected ambulance response times.
Ellen Greer, Glan Clwyd Hospital director, was the ‘silver on-call’ staff member monitoring activity at Wrexham Maelor, Glan Clwyd and Bangor hospitals during the weekend during which Mrs Jones died.
She said on the Saturday Glan Clwyd Hospital was classed at the highest level in terms of pressures and demands did increase later in the day with several ambulance service vehicles waiting outside the hospital.
“It was a difficult weekend across North Wales,” she said. “We know January 2, 3 and 4 are traditionally very busy, with an influx to GPs, WAST and the health board. There would have been a lot of plans in place.”
The inquest heard that in October 2015 a new response model had been introduced across WAST, which saw a number of types of calls received reclassified from red – the most serious – to amber 1 or 2.
Under the new model the ambulance service was able to request an immediate release of ambulances from hospital upon receiving a red call, but not for amber 1 or 2.
The call made about Mrs Jones’ condition was initially categorised as an amber 2 priority and had only been escalated to red after she went into cardiac arrest.
Karl Hughes, WAST locality manager for Wrexham and Flintshire during the weekend, was responsible for ensuring there were enough staff and resources to cope with demand.
He told the inquest a “huge amount of planning” had gone into the weekend as the ambulance service had been able to draw on past data and were expecting a four to five per cent increase in demand on the previous year.
But he said at 10.40am he identified there were nine ambulance service vehicles outside Glan Clwyd Hospital and by 1pm amber 1 priority calls were “stacking up”.
Asked by the coroner whether the length of time Mrs Jones’ family had to wait for an ambulance was acceptable, he said: “It is not what the organisation wants but we were doing everything we could at that time.”
Mr Hughes said by 3pm he identified 16 WAST vehicles waiting outside the three hospital sites across North Wales, adding that others were occupied on calls and meaning the service had fewer vehicles to respond to calls.
He said that just before midnight there were still issues with delays and efforts were being made to maximise availability of ambulances.
Julie Smith, Wrexham Maelor Hospital assistant director of nursing, told the inquest an investigation following Mrs Jones’ death led to the creation of an action plan which tied into work the health board was already doing to improve patient flow at the hospitals.
Gill Pleming, of the Welsh Ambulance Service Trust, told the inquest that following Mrs Jones’ death the ambulance service had been issued guidance enabling them to request immediate release of ambulances to respond to amber 1 level calls.
The coroner described the incorrect categorisation of Mrs Jones’ call as “a pivotal issue” and told the hearing Mrs Jones had “left a legacy” which would save lives in the future.
Reaching a narrative conclusion, she said: “Mrs Jones was incorrectly categorised as an amber 2 priority under a new approach at that time of WAST to responding to 999 calls. She should have been categorised as amber 1.
“A clinician telephoned Mrs Jones and failed to correctly categorise her as an amber 1 priority.
“A further 999 call at 12.08am by Mrs Jones’ husband resulted in Mrs Jones being categorised as amber 1 but there were no WAST resources free to assist her as all ambulances were either waiting to offload outside emergency departments of on red calls which took priority.
“At 12.14am Mrs Jones’ husband telephoned 999 as Mrs Jones had gone into cardiac arrest. She was categorised as red priority and an ambulance arrived at 12.21am.
“Despite the effort of her family and paramedics, Mrs Jones died at 12.45am from left ventricular failure due to an old myocardial infection.
“When WAST introduced the new system of prioritising 999 calls they failed to consider the impact of the use of urgent release of ambulances from emergency departments, known as red release, on the newly categorised amber 1 patients.
“Had this been done and had Mrs Jones been correctly categorised from the outset an ambulance could have been released from the emergency department had no other resources been available in the community.
“Although it cannot be established with certainty that Mrs Jones would have survived if help had reached her promptly after the first call, it is reasonable to find that she would have survived long enough to be transported to hospital for consideration of further medical treatment.”
She added both WAST and Betsi Cadwaladr University Health Board had taken steps to address the issues raised.
Following the conclusion of the inquest, Welsh Ambulance Service bosses issued an apology to Trudy Jones’ family.
Claire Bevan, the Welsh Ambulance Service’s executive director of quality, safety and patient experience, said: “We would like to extend our deepest sympathies to Mrs Jones’ family.
“The trust launched a full investigation following Mrs Jones’ tragic death to understand exactly what happened. We have shared our findings with Mrs Jones’ family and are truly sorry we did not meet our standards in answering and reassessing their call. The colleagues involved have been retrained following this sad incident.
“As the inquest heard, if the call had been correctly categorised, we would have regrettably had no nearby ambulance crews available to send as a result of the significant pressures across the whole system that night.
“Since Mrs Jones’ death we have taken a number of steps to improve the safety of our patients.
“This includes revising our arrangements with health board colleagues to allow ambulance crews to be released from outside emergency departments to respond to amber 1 (serious) calls, as well as red (immediately life threatening) calls.”