Dad died from head injury after paramedic didn’t take him to A&E during ‘phone a doc’ pilot scheme
Adam Frere-Smith died after he suffered a fractured skull and haemorrhage
A TRAGIC dad was one of THREE patients who died during an ill-fated pilot trial that resulted in crossed lines between paramedics and GPs, an inquest heard.
Adam Frere-Smith, 48, of Cromer, Norfolk, died after he suffered a fractured skull and a haemorrhage but was not taken to hospital because a paramedic thought it was a "minor wound".
Ambulance chiefs have now apologised to the father-of-four and well-liked volunteer beach lifeguard's devastated family.
The three deaths occurred during a year-long scheme designed to cut unnecessary patient trips to A&E departments.
But the inquest was told how three people died and a fourth needed intensive care after serious failings by paramedics and GPs.
The decision not to take Mr Frere-Smith to hospital was made after the paramedic spoke to a GP based at ambulance headquarters - despite it clearly breaching NHS guidelines.
That conversation was made possible because of the trial introduced by East of England Ambulance Service Trust (EEAST) last year.
The controversial initiative gave paramedics the chance to call GPs based at ambulance headquarters to discuss treatment options for patients while at the scene.
Senior figures hoped it would ensure more patients were given the correct treatment and not taken to busy hospitals unnecessarily.
But at the inquest Dr Tom Davis, EEAST's deputy medical director, admitted they "did not have the oversight to ensure the service was understood by everyone and used appropriately by everyone".
Details of the other two patients who died have not been made public.
Johanna Thompson, assistant coroner for Norfolk, said she had been given assurances by EEAST that any new such scheme would be "heavily monitored".
She recorded a verdict of accidental death.
Following the hearing EEAST must now complete the action plan by the middle of next month.
Ms Thompson said: "The ambulance trust has accepted that the assessment of Mr Frere-Smith was not thorough and that his head injury was not fully explored by the paramedic or GP.
"I shall require the ambulance service to provide an update as to the progress of the action plan and that the family be kept updated."
We have carried out a full investigation to identify the mistakes that were made and to put in place actions to improve the service in the future
Dr Tom Davis, deputy medical director of EEAST
Last night Dr Tom Davis, deputy medical director of EEAST, said: "We have apologised to the family, an apology we reiterated in the coroner's court today.
"We have carried out a full investigation to identify the mistakes that were made and to put in place actions to improve the service in the future."
"The trust recognises that mistakes were made in the care of Mr Frere-Smith, who should have been taken to hospital. Both clinicians will be going through a thorough review of the incident."
Mr Frere-Smith battled alcoholism, as well as anxiety and depression, towards the end of his life.
As a result he moved from Cromer to live with his mother, Patricia Frere-Smith, in Norwich, in a bid to improve his health.
On November 15 last year she found her son in the bathroom. It appeared he had fallen and banged his head on the basin sink next to the toilet.
Mr Frere-Smith was bleeding from his head but paramedic Jeff Billings, called to treat him, thought it was merely a minor wound.
He cleaned the wound and, after discussing the case with a GP working with the ambulance service, decided he did not need to go to hospital.
On the evening of the 16th - about 24 hours after his fall - the shocked pensioner found her son lying on the bedroom floor.
She quickly rang for an ambulance again but despite frantic attempts by paramedics to save him Mr Frere-Smith had died.
He chose not to despite guidelines from the National Institute for Clinical Excellence stating that patients with head injuries should be taken to hospital if the patient is drunk.
Dr Peter Harvey, the GP based in ambulance headquarters who spoke to Mr Billings on the phone, told the inquest: "I felt I wasn't being asked about the head injury.
"My role was to satisfy myself that he [Mr Frere-Smith] had help with his ongoing problems like the alcoholism."
When asked about the pilot trial, Dr Harvey, a GP in Holt, said the expectation of paramedic and GP "didn't match".
Mr Frere-Smith's family said they were stunned to learn the failed trial had cost more lives.
In a statement after the inquest, they said: "We are utterly devastated by the loss of our father, son, and brother Adam, and listening to the evidence in court today has been unimaginable.
"We accept the trust's acceptance of the systemic failure which significantly contributed to Adam's death.
"We are disappointed that as a family we have not been kept informed of the trust's updated action plan and are shocked to learn that Adam's death was not an isolated one during this trial.
"Our hearts go out to their families.
"Whilst there was a timely response to the initial call which is indicative of effective front-line service, Adam was let down by the trust's systemic failures - and for our family we have paid the ultimate price."
Mr Frere-Smith was one of 12 siblings and had four children, Oliver, Jessica, Wesley and Esme.
He co-founded North Norfolk Surf Lifesaving Club in 2007 and was a key figure in helping it grow from a handful of members to more than 100.
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