Man, 28, collapsed in Kilburn street dies after 999 call handlers fail to send ambulance in time
PUBLISHED: 11:07 05 January 2016 | UPDATED: 11:10 05 January 2016
A 28-year-old man died after London Ambulance Service (LAS) staff failed to send an ambulance to a street in Kilburn in time to save him, a coroner’s report has revealed.
David Sweeney lay on the pavement in Oxford Road, unconscious and vomiting but 999 call handlers failed to respond quickly enough because they thought he was only “sick” and not passed out.
He suffered a cardiac arrest minutes before paramedics reached him in April – more than 90 minutes after an ambulance should have been sent. The target response time for an ambulance to reach an unconscious person is eight minutes.
Mr Sweeney died a week later at the Royal Free Hospital in Hampstead.
Senior coroner for inner north London, Mary Hassell, criticised the LAS in a prevention of future death (PFD) report published last August but only now revealed to the public via a Freedom of Information request seen by the Times.
Only a few months earlier, Ms Hassell had written to the LAS about another case where an unconscious five-year-old child died after staff sent an ambulance too late.
She wrote: “I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients.”
A passer-by called LAS at 4.47pm on April 18 after seeing Mr Sweeney lying unconscious on the ground. The Leicestershire man had been drinking alcohol.
The caller said the man had been unconscious but when asked by an emergency medical dispatcher if he was a “little bit awake”, he said yes.
The call handler then incorrectly selected the protocol for a “sick person” rather than for an “unconscious person”.
Instead of an ambulance reaching Mr Sweeney within the target time of eight minutes for someone who is passed out, an ambulance only arrived on the scene one hour and 40 minutes after the passer-by called 999.
Even then, the ambulance was only prompted by a call from the Metropolitan Police Service, who found Mr Sweeney in the street.
In her report obtained by The Evening Standard after an inquest into his death in August, Ms Hassell wrote: “One of the intensive care consultants who looked after Mr Sweeney in the following days gave evidence that if Mr Sweeney had been in hospital at the time of his cardiac arrest, he probably would have survived.”
She instructed LAS to take action to prevent future deaths of this kind.
In a formal response, LAS chief executive officer Dr Fionna Moore MBE wrote to Ms Hassell in October to say: “Assessing the level of consciousness by a telephone assessment is challenging and an area where emergency medical dispatchers have a higher incidence of error and where potentially a negative impact for the patient may follow.”
She added that both cases were being used to trial a new training system for 999 call handlers.
In November, the Care Quality Commission (CQC) took the unprecedented step of placing the London Ambulance Service NHS Trust in special measures after rating it as ‘inadequate’.
The trust was slammed for its poor ambulance response times and inspectors also noted a culture of harassment and bullying in the workplace with inadequately trained staff and a lack of available equipment needed for their jobs.
While the CQC found that the trust delivered services that were caring it ruled improvements were needed on safety, effectiveness, responsiveness and leadership.
A team of 54 CQC inspectors probed all aspects of the trust including interviewing patients during three weeks in June.
Dr Moore MBE issued an apology for ‘falling short of some of the standards CQC and Londoners expected adding that the trust ‘prioritised its response to the most critically ill and injured patients’.