22.04.2010

Coroner criticises the North West Ambulance Service

A distraught mum whose eight year old son died from a sudden onset of diabetes has today demanded immediate action after hearing at his inquest that a catalogue of blunders and missed opportunities were responsible for his death.

Frantic Melanie Austin and family friend Owen called the emergency services when eight-year-old Louis became ill and was struggling to stay awake, breathing with difficulty and rapidly losing weight.

But, despite describing these symptoms first to a emergency medical call handler, and then a senior paramedic, his potentially fatal condition was not deemed serious enough for an ambulance to be sent.

Ms Austin and Owen were told Louis’ case would be referred instead to a GP and to expect a call but, desperate for help, Ms Austin made the call to the out-of-hours service, Mastercall, herself. She was then called back by Dr Leigh, the on call GP, who told her that her son had swine flu and should be quarantined. She was told to give him Tamiflu but, less than 48 hours later, Louis died.

A Coroner today criticised the north west ambulance service and concluded that Louis died of natural causes contributed to by neglect.

Until the inquest the family, from Old Trafford in Manchester, had never received an apology from the ambulance service and now they and their lawyers, Irwin Mitchell, are demanding that lessons are learnt from Louis’ tragic death to ensure similar mistakes cannot be made in the future. They are yet to receive an apology from Mastercall.

Speaking on the family’s behalf, solicitor Sue Tyson, from Irwin Mitchell in Manchester, said: “The family are truly devastated to have lost a much loved son and brother. But to learn that his death could have been avoided has, understandably, made them question the systems and procedures in place for the emergency services and indeed out of hours GP’s.

“Miss Austin and her family have had to wait nine months for any kind of apology, and to hear the full story about how he was failed so badly by the system. That is simply not acceptable. They deserve far better than that.

“They now know that, on three separate occasions, medical staff failed to appreciate the serious nature of Louis’ symptoms and so the opportunity to treat the condition that, eventually, took the life of an eight-year-old boy was missed. For his mother, Melanie, that is almost too much to bear.”

Miss Tyson continued: “Louis’ family didn’t know he had diabetes and placed their trust in the healthcare experts they spoke to. They were badly let down and are determined to hold the organisations concerned to account to ensure this never happens to any other family in the future, anywhere in the NHS.

“We will be continuing to investigate the way the emergency services initially handled the call for help. Louis’ family deserve answers and a reassurance from the highest levels that every step will be taken in the future to ensure this cannot happen again.”

Following Louis’ death on July 13, 2009 investigations were conducted by Trafford Primary Care Trust (PCT) into the care provided by the North West Ambulance Service and Mastercall.

The report issued following the investigation found that the emergency medical dispatcher at NWAS did not correctly code the call in line with the Advanced Medical Despatch Priority System and failed to correctly asses Louis’ condition. Had he done so an ambulance would have been sent within 19 minutes.

The investigation found that the senior paramedic failed to ask at least seven of the necessary questions that, had she done so, would have prompted the decision for an ambulance to be send within eight or 19 minutes.

It was also concluded that Mastercall failed to provide good clinical care in line with recommendations made by the General Medical Council (GMC) during a pandemic situation.

The PCT obtained a report from the Dr Amin, Consultant paediatric Endocrinologist. He confirmed during the inquest that a blood test carried out within minutes of Louis arriving at the hospital would have confirmed the diagnosis of diabetic Ketoacidosis. With treatment at that time Louis would have made a full recovery.