Coroner Seeks National Clarification Of How Ambulance Services Prioritise Asthma Attacks Following Inquest Into Death Of Decorated ‘Street Warrior’

A former police officer died from an asthma attack after repeatedly pleading “help me” to call handlers who dispatched an ambulance 17 minutes after he dialled 999, an inquest heard.

Stephen Hartwell Thurman-Newell faced delays in an ambulance being sent to his home in Wincanton, Somerset, after staff continued to try and complete a triage process to establish the nature of his call despite him repeatedly pleading “help me”.

By the time the first paramedic arrived at the 62-year-old’s property, 36 minutes had passed since Stephen had initially dialled for help saying he could not breathe.

Stephen, a decorated officer who was known as “Street Warrior” by his former police colleagues, was pronounced dead around 30 minutes later.

Following his death his wife Susan, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the response of South Western Ambulance Service NHS Foundation Trust and support her through the inquest process.

Tony Williams, senior coroner for Somerset, has now requested details of how Ambulance Trusts across the country class asthma attacks with a view to potentially making recommendations that all Trusts should class incidents as the highest possible emergency.

It comes after an inquest into Stephen’s death in which the coroner recorded a narrative conclusion.

Expert Opinion

“Stephen’s sudden death has had a huge impact on the family who are still struggling to come to terms with what happened to him.

“For more than two years Susan and the rest of the family have had a number of concerns about the events that unfolded in the lead up to his death. Sadly some of the evidence heard during the course of the inquest has validated these concerns.

“While nothing will make up for Stephen’s death we acknowledge that following his death, the Trust has introduced measures designed to reduce the number of delays patients suffering an asthma attack face. It is vital that staff follow these measures at all times to help prevent a repeat of the delays Stephen faced before his death.

“We also call on other Ambulance Trusts across the country to review how they deal with asthma attacks to help prevent other families suffering the pain and anguish Stephen’s family have had to endure following his death.” Eleri Davies - Senior Associate Solicitor

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After the hearing Susan said: “Stephen was a wonderful husband and father who would do anything for his family.

“He was kind and considerate and his wish to help others really shone through in his police work. Although he had mild asthma this never affected his ability to carry out a demanding job. For 30 years he served with great pride and distinction winning numerous awards and being known as ‘Street Warrior’ by his colleagues.

“Although he had retired from the police he still wanted to help others. He was still fit and healthy.

“Stephen spent the majority of his life helping and protecting people from harm. It is difficult not to think that when he needed others to help him he was let down.

“I don’t think I will ever fully understand why, when Stephen was constantly telling call handlers he was short of breath, using his inhaler and no longer able to talk, it was not classed as a top priority emergency.

“If the Ambulance Service had treated Stephen as a top priority, he might have stood a fighting chance. It is difficult not to think he would still be alive today, if they had.

“This was the first time Stephen had called 999 and he lost his life. What makes his death even harder to come to terms with is if Stephen had suffered his asthma attack a few months later he probably would have been allocated an ambulance quicker because the Trust had changed its response categories.

“Our family will never be the same again without Stephen. All we can hope for now is that Stephen’s death is not totally in vain. We urge all Ambulance Trusts across the country to class asthma attacks in the same category as other life-threatening conditions so those in need can receive the treatment they need as soon as possible and so other families do not have to endure the feeling of hurt and loss we do.

“I can state with absolute certainty that Stephen would not want what happened to him to happen to anyone else.

“I am left agreeing with Søren Kierkegaard, the Danish philosopher and theologian, who said. “The most painful state of being is remembering the future, particularly the one you'll never have.”

Background

Stephen served with Kent Police for 30 years. For many years he was an acting sergeant and was a response officer, until the end of his service. He also served in Special Branch, based at the Port of Dover. He received many accolades, including a number of chief constable and judge commendations.

After retiring in 2010, he and Susan, who had been together 20 years, moved from Ramsgate to Somerset. Stephen, a father and stepfather, was employed as a driver collecting students from across Somerset and Dorset and transporting them to Kingston Mauward Agricultural College, as well as a pall bearer for two funeral directors.

On 16 September, 2016, he returned home from work. At around 8.50pm he had a phone conversation with Susan, a licensing officer with Wiltshire Police, who was visiting her son in Thanet, Kent, overnight.

During the call Stephen, who had mild asthma and had only suffered one serious attack in the 20 years he had been with Susan, said he needed his inhalers, the inquest heard. During the conversation he used the inhalers two or three times. When Stephen was not speaking Susan could hear he was short of breath but he was in good spirits, the court heard.

However, just before 9.15pm Stephen dialled 999, telling the operator he was struggling for breath. During the call Stephen repeatedly said “help me”. He gave his address and phone number, stating that he had his inhalers with him, the hearing was told. He also told the call handler, that he would try to open the door.

The operator continued to ask questions and around four minutes into the call they classed Stephen’s call as ‘respiratory distress non-trauma’. The Trust’s own response time for this type of call was 19 minutes.

The operator ended the call at 9.21pm, after advising Stephen to call back if his symptoms worsened. Around 10 seconds later Stephen was reconnected by a BT operator, because he had not hung up and she advised the call handler that Stephen ‘‘needed help’’.

The second call was initially logged as a new call. Shortly into the call the phone operator went to ask for the opinion of a clinical supervisor based in the control room, telling their colleague that “there is no massive rush” to break off from what they were doing because “he’s not actually saying anything other than, help me.”

After the clinical supervisor reviewed the call, it was established it was a duplicate incident call.

At 9.32pm a rapid response vehicle was allocated from Yeovil, around 15 miles away. The vehicle arrived around 19 minutes later. On arrival the paramedic twice requested ‘priority one back up’ – the highest level. However, he received no immediate response from the Hub and issued a General Broadcast call to his colleagues, for back-up. The Hub responded to him after this broadcast and a specialist paramedic and a double crew ambulance were both despatched at 9.54pm, arriving around 18 minutes later.

Stephen was pronounced dead at around 10.30pm.

Following Stephen’s death South Western Ambulance Service NHS Foundation Trust carried out an internal investigation. It found that Stephen’s initial 999 call was challenging but complied with Trust standards, achieving a score of 94 out of 100.

However, an independent audit by another ambulance service, requested by the Coroner, gave the call a mark of 66 out of 100. It found that it was “obvious from the beginning of the call” that Stephen was struggling to breathe and could not hear the call handler. It found that the call handler did not listen carefully throughout the call and could have issued an alert that Stephen had breathing problems earlier.

South Western Ambulance Service’s report found the root cause of Stephen’s delay was high demand for emergency services.  Its investigation also found that two rapid response vehicles staffed by specialist paramedics were available at the time of the 999 call. However, it remained unclear why neither of these were despatched when they should have been, the inquest was told.

Following guidance from NHS England, the Trust has updated how it classifies emergency calls to include more categories.  It found that during periods of high demand patients with the most serious emergency situations could face delays.

South Western Ambulance Service now allocates the highest emergency response to patients suffering asthma attacks – the same as those with emergencies such as a cardiac arrest.

Stephen used to play football and rugby for Kent Police, was a Trainer for the Police gym, continuing to use the gym regularly since moving to Somerset and was a qualified PADI Advanced Open Water, who dove in the challenging conditions of the English Channel and abroad.

He also leaves behind a son and daughter, Anthony & Penny Louise and two stepsons, Richard and Matthew, four granddaughters and a step granddaughter and grandson.