NHS Trust Serious Incident Report Reveals Critical Failings

The distraught wife of a 38-year-old man who died after ambulance staff took SIX hours to respond to an emergency call and failed to act on the ‘red flag’ symptoms of meningitis says she hopes lessons are learnt by medical staff to prevent the same mistakes in future.

An inquest into the death of Mthuthuzeli Mpongwana originally from South Africa but who had moved to Bedminster in Bristol, heard how he started to complain of a headache, fever and struggled with bright lights and his wife was so worried about his condition she called the NHS 111 service on 5^th January this year. The 111 clinician recognise this may be meningitis and called for an ambulance. Her husband rapidly deteriorated, started vomiting, struggled to stand up, his skin turned grey and he became delirious and confused.

Following a wait of three hours a paramedic arrived at the scene in a rapid response vehicle. The paramedic failed to act on the seriousness of the potential meningitis symptoms and downgraded the ambulance response to the lowest priority. This meant that no ambulance arrived at their home to take them to the Bristol Royal Infirmary for a further three hours, nearly six hours later after the initial 111 call. Mthuthuzeli was taken straight to the resuscitation room as his eyes were bulging and he had lost control of his arms and hands.

After he suffered a stroke and his brain began to swell and medics told his wife there was nothing more they could do and his life support machine was turned off two days later on 7^th January.

His devastated wife, Lisa Armitage, from Bristol instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the circumstances leading up to Mthuthuzeli’s death and the medical care he received from the South Western Ambulance Service NHS Foundation Trust.

Following the inquest into his death at Avon Coroner’s Court, HM Coroner Maria Voisin recorded a narrative conclusion and said: “Mr Mpongwana died from natural causes contributed to by failure to take appropriate action in the face of an obvious need that failure arose at around 1:50am when a P1 (Priority One) back up should have requested and benzo penicillin should have been administered. The inappropriate care given resulted in a missed opportunity to render medical treatment.”

Expert Opinion

“This was a tragic case where a man needlessly lost his life because of errors by medical staff which could and should have been avoided.

“Lisa repeatedly told the paramedic about Mthuthuzeli’s symptoms and his declining condition and he was displaying all the classic and typical symptoms of meningitis. Worryingly the paramedic dismissed her pleas for help and ignored the seriousness of his condition when he should have received urgent medical care.

“The family would like reassurances by the Trust to ensure that all their staff are fully trained to notice and diagnose the symptoms of meningitis to prevent anyone else suffering from any similar issues.

“Sadly on this occasion the paramedics didn’t seem to recognize the symptoms of meningitis and should have followed the basic guidelines on treating someone with suspected meningitis and Lisa has suffered the consequences. The Inquest has heard that if they had spotted his meningitis sooner and been able to treat him effectively and his chances of survival would have been approved.”
Julie Lewis - Partner

A Serious Incident Report was also carried out following Mthuthuzeli’s death which showed several failings by the NHS Trust including:

• The paramedic did not recognise signs and symptoms of potential sepsis and meningitis
• The inability of another member of staff to effectively undertake all welfare calls within the required time frames
• Three calls missed during the time the patient waiting for assistance
• Paramedic not familiar with CG19 – the guidelines for recognition and treatment of sepsis and meningitis.

Speaking after the inquest, Lisa, 28, said: “I would like to thank the Coroner for a thorough investigation into my husband’s death and it has helped me gain a better understanding as to what happened in the hours leading up to his death.

“Mthuthuzeli and I had just settled into our new life in the UK together and he had just started applying for jobs. When he died I was working as a theatre assistant at St Michael’s Hospital but have not been able to return to work as I find it too distressing seeing people having surgery as it reminds me of watching my husband lying motionless on a life support machine.

“I am extremely concerned about the treatment he received by the ambulance staff and I was baffled at the time that they didn’t seem to be taking into consideration his symptoms and the urgency of his situation.

“I am still amazed now that the paramedics took such a long time to realise the red flag symptoms of meningitis that Mthuthuzeli was experiencing and it took them six hours to send an ambulance. It is incredibly well known that you have to act quickly if someone starts to suffer from symptoms of meningitis and his death could have been avoided if they had taken the care and attention to give him the medical care he rightly deserved.”

Sue Davie, Chief Executive at Meningitis Now, said: “Our thoughts are with Lisa and her family at this sad time. We know how quickly meningitis strikes and the devastation it causes. Meningitis is often difficult to diagnose, which is why at Meningitis Now, we work tirelessly to raise awareness and educate on the signs and symptoms, and provide lifelong support to families who are trying to cope with the impact of this horrific disease.”

If you or a loved one has suffered due to meningitis misdiagnosis, our medical negligence claims team could help you to secure compensation. See our Meningitis Misdiagnosis Claims page for more information.