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Woman dies following call handler's decision.

A DECISION by a NHS 111 call handler to ignore and overrule a red warning to send an ambulance to a woman struggling to breathe probably cost the patient her life, a Bradford inquest heard.

Dinner lady Maureen Johnson, 52, had been waiting six hours after that call to be seen by an out-of-hours GP when she collapsed at her on November 8 2015 from a cardiac arrest.

The inquest heard how paramedics and doctors at Bradford Royal Infirmary had to work on her for more than 70 minutes to re-start her heart and she had to be ventilated. The prolonged cardiac arrest caused major brain damage and four days later her life support was withdrawn.

ICU consultant Dr Paul Stonelake told the inquest: "I think it's likely if she had been in hospital before her cardiac arrest, things would have been different. If it had been treated sooner, the brain injury would not have occurred."

The inquest heard how the original call handler had decided not to request an ambulance because Mrs Johnson said she felt out of breath, but did not sound so on the phone.

Instead of sending an ambulance as the call handler's pathway system had flagged up, the call was referred to a nurse who said she would pass on Mrs Johnson's details to the nearest out-of-hours service to see a doctor in the next two hours.

But those details were sent to Oldham by mistake rather than Bradford.

After hearing nothing, Mrs Johnson made a second NHS 111 call telling another operator: "I think I'm going to die. My chest is tightening up."

She was told she had not been forgotten. A GP did call her back. He promised a home visit within two hours but had not done so by three hours later and she collapsed.

Michaela Littlewood Prince, from NHS 111 Quality Assurance, who carried out a serious untoward investigation triggered by Mrs Johnson's death, said lessons had been learned, action had been taken and national improvements were being made.

Coroner Oliver Longstaff said Mrs Johnson could have got to hospital sooner and added: "The decision not to send for an ambulance at the first call represented a missed opportunity to get Mrs Johnson into hospital six hours before she eventually got there.

"Because she did not sound out of breath the red flag coming up on the call handler's pathway system was ignored and overruled. I'm satisfied that, had the opportunity been taken, it is more likely than not that Mrs Johnson would not have sustained the catastrophic brain injury she did and she would not have died when she did."




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