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March 2019

Date: 17 April 2019

  • Details:

    The patient collapsed at home with breathing difficulties. The patient’s wife rang for an ambulance. 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 patient’s wife complained that the resources did not arrive 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 then audited. 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. Statements were taken from both the Community First Responder (CFR) and the dispatch team. The CFR arrived on scene within seven minutes of the 999 call, however had difficulties finding the property so didn’t arrive on scene with the patient 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 (RRVs) locally however the dispatch team decided not to dispatch them as an ambulance was about to become available nearby. The dispatcher didn’t however document or record this decision. When the CFR contacted the Emergency Operations Centre (EOC) to update on the patient’s condition, again 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 until 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 team's 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 investigator 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. The dispatcher has completed reflective practice and further training. Sincere condolences and apologies were given to the family for their sad loss.

  • Date:
    01 March 2019