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February 2019

Date: 19 March 2019

  • Details:

    The complainant’s husband collapsed, had breathing difficulties breathing. The complainant rang 999. The complainant asked the call handler if she could fetch oxygen from her place of work but was told she had to stay with her husband. It was 17 minutes before the first responder arrived and he said that he only had ten minutes of oxygen left. The ambulance arrived after 20 minutes and despite the crews efforts the patient passed away. The complainant did not believe the resources arrived within a suitable time frame.

  • Findings:

    The investigating officer reviewed the Computer Aided Dispatch (CAD) notes and listened to the 999 call. This call was audited. Statements were taken from both the Community First Responder (CFR) and the dispatch team. The audit department noted that based on the description of the patient’s breathing the call was incorrectly coded as a C2 and should have been a higher priority C1. The CFR arrived on scene within 7 minutes of the 999 call however had difficulties finding the address so didn’t arrive on scene until about 15 minutes after the call. It was also discovered that at the time of the call there were two available Rapid Response Vehicles (RRV's) locally however the dispatch team decided not to dispatch them as an ambulance was becoming available nearby shortly, he didn’t however document this decision. When the CFR contacted the Emergency Operations Centre (EOC) to update on the patient’s condition, nothing was recorded in the CAD record or highlighted to a clinician for further review. It was found that the CFR did however have enough oxygen and was only just starting to run out as the ambulance arrived on scene.


  • Lesson learnt / action taken:

    The call handler completed a reflective practice in which she identified the error with the coding and was also given further training to assist with future calls. The dispatch teams decision regarding not to dispatch the RRV was within the guidelines however he has learnt from this and been reminded to document his decisions at the time. The dispatch team leader has also identified that action should have been undertaken regarding escalating the CFR’s call and the importance of documented what he was told and the need for escalation of similar incidents.

  • Date:
    01 February 2019