A woman suffering breathing difficulties would probably still be alive if a NHS call handler had not overruled a red warning to call an ambulance – because the patient did not seem out of breath on the phone, an inquest heard.
Dinner lady Maureen Johnson, 52, eventually collapsed six hours after telling a NHS 111 operator on a second occasion: “I think I’m going to die. My chest is tightening up.”
The inquest heard Mrs Johnson suffered from cardiac arrest on November 8 last year, but died four days later after her condition left her with major brain damage.
ICU consultant Dr Paul Stonelake told the inquest: “I think it’s likely if she had been in hospital before her cardiac arrest things would have been different.
“If it had treated sooner, the brain injury would not have occurred.”
The inquest heard Mrs Johnson rang 111 and told them she felt out of breath – but the call handler had decided not to call for an ambulance because the patient did not sound it on the phone.
Instead of sending an ambulance like the call handler’s pathway system had flagged up, the call was referred to a nurse who said she would pass on Mrs Johnson’s details to the nearest out-of-hours service to see a doctor in the next two hours.
But, by mistake, those details were sent to Oldham rather than Bradford.
Maureen made a second call to NHS 111 telling them she thought she was going to die – and was assured she had “not been forgotten”.
A GP did call her back and promised a home visit within two hours – but that time had exceeded by more than one hour when she collapsed.
Paramedics and doctors at Bradford Royal Infirmary had to work on her for more than 70 minutes to re-start her heart and she had to be ventilated.
Mrs Johnson suffered severe brain damage – and her life support was terminated four days later.
Michaela Littlewood Prince, from NHS 111 Quality Assurance, who carried out a serious untoward investigation triggered by Mrs Johnson’s death, said lessons had been learned and action had been taken.
Coroner Oliver Longstaff, who said Mrs Johnson could have got to hospital sooner, said: “The decision not to send for an ambulance at the first call represented a missed opportunity to get Mrs Johnson into hospital some six hours before she eventually got there.
“Because she did not sound out of breath the red flag coming up on the call handler’s pathway system was ignored and over ruled.
“I’m satisfied had the opportunity been taken it is more likely than not that Mrs Johnson would not have sustained the catastrophic brain injury she did and she would not have died when she died.”
Following the inquest, Maureen’s husband Stanley said in a statement: “She was 52. This is no age to die. We miss her everyday.”