Tactical Commander Did Not Fully Explore Patient’s Condition

A wife died as a result of an ectopic pregnancy after waiting more than two-and-a-half hours for an ambulance when her 999 call was incorrectly downgraded, an inquest heard.

When Gail Bailey started experiencing severe abdominal pains on holiday, her husband Ryan, called an ambulance. He informed the operator that his wife was nine weeks pregnant and that a hospital had advised she underwent a scan because she could be suffering from a potentially life-threatening pregnancy complication. 

However, an East Midlands Ambulance Service tactical commander called Ryan back to complete a “blind” triage process. The commander was not logged on to a computer system which would have taken them through specific questions to fully establish the emergency response a patient required.

That meant that Gail’s condition was “not fully explored” and the decision to downgrade her emergency response was “not appropriate,” an internal ambulance service investigation found.

Gail arrived at Boston Pilgrim Hospital – 25 miles from where the couple were staying – nearly four hours after the original 999 call. She was pronounced dead around an hour later.

Following Gail’s death, her husband Ryan, of Rotherham, instructed expert medical negligence solicitors at Irwin Mitchell to investigate her care under East Midlands Ambulance Service NHS Trust. 

The Trust has already admitted liability for her death and today an inquest concluded that Gail’s death was “wholly preventable”. The Coroner, Paul Smith, confirmed that there were a “number of opportunities missed” to handle Gail’s call differently and had she arrived at hospital by 7.40pm, she would have survived. . 

Ryan, 37, has now joined his legal team at Irwin Mitchell in calling on the ambulance service to ensure it learns lessons.

Anne Brundell, specialist medical negligence solicitor at Irwin Mitchell representing Ryan said: 

Expert Opinion

“This is a truly tragic case which, understandably, has left Ryan struggling to come to terms with what happened on the day his wife died.

“We believe that if Gail’s call had not been downgraded, an ambulance would have arrived sooner, Gail would have received appropriate hospital treatment and she would still be alive. The Ambulance Service’s own report and the inquest have also highlighted extremely serious failings in the care Gail received.

“Gail’s death sadly highlights how dangerous ectopic pregnancies can be. It is now vital that the Ambulance Trust learns lessons to improve patient care.” Anne Brundell - Solicitor

Ryan and Gail, of Kimberworth, met in 2014 and married in May 2017. 

They were holidaying at Promenade Caravan Park in Ingoldmells, when on 6 August, 2017, Gail went back to the caravan because she had stomach pains. 

Ryan, who was worried because Gail had miscarried in March 2017, called Rotherham General Hospital and was advised that she visited a local hospital for a scan because she could have an ectopic pregnancy. 

When Gail tried to sit upright on the bed she passed out so Ryan dialled 999 at about 5pm. 

An inquest at Lincoln Cathedral Centre was told that Gail was placed in the second highest response category – which has a target response time of 18 minutes – and an ambulance was dispatched.

However, this was stood down on the authority of the tactical commander at 5.13pm because it was thought the crew might be needed for a more life-threatening incident.

The tactical commander was only due to be providing management support to cover staff shortages and not clinical assessments. However, because no operators were available they volunteered to triage Gail’s condition when Ryan was called back to say the ambulance had been stood down.

The tactical commander was working on a laptop and was not logged on to the triage system. She conducted the triage process based on her experience and not specific questions on the system, speaking only to Ryan and not Gail, the court heard. 

At 5.18pm Gail’s call was downgraded to the ambulance service’s third category designed for “immediately none life-threatening” calls. It has a target that 90 per cent of calls are dealt with within two hours.  

Just before 5.50pm another ambulance was assigned to the call. However, 20 minutes later this ambulance was diverted to a high category call.

Ryan dialled 999 for a second time around 6.40pm saying his wife was drifting in and out of consciousness. This call was upgraded to the second highest category. 

Another ambulance was finally dispatched at 7.30pm, arriving at 7.40pm – two hours and 38 minutes after Ryan’s original 999 call. 

Paramedics started to transport Gail to hospital at 8.16pm placing ‘alert calls’ that she had a suspected ectopic rupture. 

Gail arrived at hospital just after 8.50pm and was pronounced dead 50 minutes later. 

East Midlands Ambulance Service’s internal investigation report found it was “likely that the delayed attendance” to Gail “has been detrimental to the subsequent outcome.” 

The commander, who had received training about the complication in pregnancy the previous day, “did not believe ectopic pregnancy was a factor”, however, the report said it was the “likely diagnosis” based on the information available. 

The tactical commander also accepted that some of their decision making had been influenced by pressures that staff were under on the day Gail died, the report added. 

The report made 12 recommendations including that an ectopic pregnancy learning programme is developed and a review of the clinical assessment process is conducted. 

Staff are also to receive official memos about only downgrading calls based on clinical needs and the role and responsibilities of their job is to be “outlined” to the tactical commander.

The Court heard that East Midlands Ambulance Service is in the process of making a number of changes to their resourcing in an attempt to prevent further deaths. 

The Coroner is also intending to issue a Preventing Future Deaths report to the Trust in charge of Pilgrim Hospital. The Court heard that two pre-alert calls were made by paramedics from the ambulance, yet there was no-one waiting at the hospital to receive her. Although this did not make a difference to Gail, it could have potentially fatal outcomes for other patients and therefore the Coroner intends to issue a Preventing Future Deaths report asking Pilgrim Hospital what happens to these pre-alert calls to ensure that there is an appropriate team ready to receive a patient in need of resuscitation.

After the hearing, Ryan said: “We had been trying for a baby and were delighted when Gail fell pregnant especially after the miscarriage. 

“Gail’s pregnancy had been smooth in those first few weeks and because of what happened previously we were both looking out for any changes or warning signs. 

“When I was told that Gail’s condition was not life-threatening I had to put my trust in them. I was frustrated and felt so helpless that I couldn’t do anything when she was clearly in so much pain.

“It felt like I was the only one willing to do anything to get her to hospital. One minute Gail was fine, the next thing I was identifying her body.

“I still can’t believe what has happened and the unacceptable care Gail received. We had a reasonable expectation that Gail’s call would be treated appropriately and that an ambulance would come.

“There are no words to fully describe the way I feel about watching my wife dying as we waited for an ambulance and then in the ambulance on the way to hospital.

“All I can hope for now is that Gail did not die in vain. I do not want anyone else to go through what I have been through and lose a loved one in such a horrific and needless way.”

Read about Irwin Mitchell's expertise in medical negligence cases.