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Baby Dies Following Ambulance Delays

Expert Lawyers Instructed To Investigate Whether More Could Have Been Done To Prevent Baby’s Death


The death of a six-month-old baby is being investigated after an ambulance was delayed in reaching him by almost 10 minutes because the 999 call operator did not have the appropriate training or resource to categorise the situation as urgent.

Gemma and Darren Moore are speaking out for the first time about their son Cainan’s death in October 2012 after his brain was starved of oxygen because of breathing difficulties. They have welcomed the news that West Midlands Ambulance Service NHS Trust has since made a series of improvements, including the introduction of an agonal breathing tool (guide) to help staff correctly categorise calls.

However, the couple, from Wolverhampton, say they remain concerned that the tragedy could be repeated because the National NHS Pathways Group has refused to make it compulsory for each call centre in the UK to have access to the guide.

Medical law experts at Irwin Mitchell are instructed to investigate why there was a delay of nearly 10 minutes in ambulance crews reaching Cainan when the hospital is only five minutes drive from their house and why it was nearly 20 minutes from when Gemma first dialled 999 at 11.05am on 26 October 2012, before her son could be treated when they arrived at New Cross Hospital.

Cainan died immediately after being taken off life support at 9pm later that evening as a result of severe brain injuries caused by prolonged lack of oxygen to the brain, leaving his parents Gemma and Darren heartbroken.

A Root Cause Analysis Report compiled after Cainan’s death found that:

  • The call centre allocated a rapid response vehicle to attend that was over 14 minutes away when there was a full ambulance less than two minutes distance away which was on a ‘disturbable break'.
  • The call was not coded as Red 1 (the most serious) despite Gemma saying her baby was not breathing, as there was no appropriate guidance for call centre staff on how to assess troubled breathing in babies.
  • There were staff shortages, which the Trust has acknowledged was not a new issue, which meant that staff were preoccupied with other matters and were unable to give their full attention to Gemma’s urgent call. The dispatcher has admitted to the Trust that he was pre-occupied by undertaking the management of another call.

This resulted in a seven-point action plan that included drawing up new guidance to ensure emergency codes are applied correctly; particularly in relation to babies who are breathing abnormally, increasing training to improve consistency by all call centre workers and improving documentation and note taking.

Christina Bunting, a medical law expert at Irwin Mitchell’s Birmingham office representing Cainan’s parents, said: “This is an absolutely tragic case that has left a couple heartbroken by the unexpected and sudden loss of their only child.

“We were deeply concerned to hear that there was inadequate guidance for call operators in relation to the appropriate coding allocation that should be made to calls which describe a baby as not breathing or breathing abnormally.

“We are pleased this has been rectified by West Midlands Ambulance Service NHS Trust with the introduction of an agonal breathing tool, however we believe this needs to be made compulsory within all NHS ambulance trusts to protect the safety of other patients.

“We will continue to support Cainan’s parents and liaise with the Trust to secure an admission of liability in the hope that one day they can lay Cainan to rest and begin the difficult process of rebuilding their lives.”

Gemma, 29, added: “Cainan was our only son and the most precious thing to us in the world.

“We were absolutely horrified to learn that call operators with no medical training were given the responsibility of coding the severity of calls and the only guidance they had is a 20 page document, which obviously in the heat of the moment, is not appropriate to scan through.

“What was also very concerning was that this document only advises on action that should be taken for adults with breathing difficulties and there was no guidance on the recommended course of action for babies, which effectively meant Cainan had no hope.

“What makes this all the more unbearable is Darren is an ex fire-fighter trained in giving CPR and despite being at work on the other side of the city, he may have got to us quicker than the ambulance did. We have to live with the thought every day that he might have been able to save Cainan’s life.

“We are pleased that West Midlands Ambulance Service NHS Trust has reviewed its training and guidance for call operators but we believe this needs to be rolled out across the UK so that the appropriate treatment can be provided to patients with breathing difficulties as quickly as possible. Nothing can bring our baby back but it would give us a small piece of comfort to know his death was not completely in vain.”

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