A WOMAN was found dead in her living room ten hours after an NHS 111 call
handler cancelled an ambulance when it was just one minute away from her
home, an inquest heard today.
Tragic Ann Walters, 61, died after a nurse called off the emergency response
team which had been heading to see her.
A later investigation found Pete Richardson had ‘not demonstrated an
understanding of heart failure’ when dealing with the call.
At the hearing he confessed he made a mistake and apologised to the family.
The inquest was told Mrs Walters called the NHS 111 service on December 28,
2014, asking for a doctor to be sent to her home.
Her breathlessness caused an initial call handler concern, so she was classed
as an emergency.
He was told by Mrs Walters – who at the time only had months to live – that
she had a heart defect, and so dialled 999 himself for an ambulance to be
sent to her home despite her asking to see a doctor instead.
A crew was initially dispatched from Waterlooville to her home nearby in
Portsmouth, but within four minutes a different ambulance was sent from
Queen Alexandra Hospital in the city as it was nearer her home.
However, in the meantime Mrs Walters was called at 8.24am by Pete Richardson,
a qualified nurse and clinical support desk practitioner for the 111
service.
After talking with her, he took the decision to stand down the ambulance which
was just one minute from her home.
He told today’s hearing he opted to stop the ambulance because she was
‘forthright’ in her views that she wanted a doctor instead.
Her son Lawrence Thorpe, a 25-year-old former teacher, was upstairs in his
room that day and was horrified to find her lifeless body at around 6pm.
He dialled 999 but medics who turned up pronounced Mrs Walters dead and said
rigor mortis had already set in.
Mr Richardson admitted that in hindsight, his decision was wrong, but the
qualified nurse of over 20 years said: “She sounded forthright in a way
that told me ‘no means no’.”
An investigation has since found he ‘didn’t demonstrate an understanding of
heart failure’ and was ‘unable to pick up clues from the patient’,
Portsmouth Coroner’s Court was told.
He was suspended following a review and was retrained by managers to learn
from the incident.
He has since returned to work.
Ann Walters had a heart defect which would make her go hypoxic and she would
turn blue as oxygen would not reach her vital tissues.
At the time of her death she was undergoing an assessment to decide whether or
not she needed a regular oxygen supply at her home.
She first called 111 at 8.11am the morning of her death. At that point her
long-term heart defect was leaving her breathless.
She told the handler: “I just want a doctor to come out and see me.”
She said she had picked up a chest infection and was unable to breathe, the
inquest heard, but eventually agreed to an ambulance being sent to her.
One was dispatched at 8.19am to be with her within eight minutes, before it
was turned away at 8.25am just a minute from her home .
Mr Richardson told the inquest: “During my conversation with her I had
established she was conscious and breathing, and expressed a wish to be seen
by a doctor and not an ambulance.
“I gave her advice that if her symptoms changed or got worse or if there
were any concerns in the meantime to call us back straight away on 999.”
He told how Mrs Walters refused to wake her son up, adding: “I heard she
wanted to be seen by a doctor. I thought I was complying with her wishes.
“It was extremely busy that morning.”
After closing the call, he passed the incident to the out of hours GP service
and requested a call back within an hour.
Mrs Walters’s son, Lawrence, asked Mr Richardson: “In hindsight, do you
believe your decision was wrong?'”
Mr Richardson answered: “Yes”.
Outside court, Mr Thorpe said that he found his mother’s phone under her body,
and that could have been why he never heard the calls.
The inquest heard calls to the out of hours GP service were up 30 per cent on
the previous year for the four-day bank holiday Christmas weekend.
South Central Ambulance Service apologised to Mrs Walters’ family and has
since completed a thorough investigation of the incident to ‘ensure lessons
had been learned’.
Mrs Walters declined an operation in 2007 to sort her issues as she was
‘adamant’ she didn’t want her chest opened up, doctors told the inquest.
Consultant Cardiologist Dr Philip Strike of Queen Alexandra Hospital said not
having the operation would end up in patients deteriorating, adding: “She
was aware this would kill her.”
When he last saw her he gave her less than a year to live,
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Ms Walters, who previously worked in admin for court summons, was unemployed
when she died and is survived by two children – Lawrence and Felicity, 26 –
but had four in total.
Her other daughter Heather, 29, died 12 years ago and a fourth child died
during their birth.
Senior coroner David Horsley said SCAS’ investigation of the event had been a
‘very serious and thoughtful’ one.
He ruled that Mrs Walters died of congestive cardiac failure.
He said the South Central Ambulance Service had ‘fallen below’ the standards
set for itself and that the service had learnt some ‘hard lessons’.
Expressing his sympathy to Mr Thorpe and his family, he said: “After only
talking to her for one minute the judgement was made that her condition
didn’t merit the attendance of an ambulance.
“For me the irony of this is the moment the ambulance was stood down, it
was only a minute from her home.
“It was not likely there was anything that could have been done to save
her.”