Coroner highlights ambulance service failings after road tragedy
13:34 19 January 2013
A litany of failings within the ambulance service was highlighted by Norfolk’s coroner yesterday in an investigation into the death of a young veterinary nurse.
Coroner William Armstrong described “systemic and individual” failings within the East of England Ambulance Service Trust (EEAST), which meant Catherine Barton’s chances of survival in a car crash were “substantially” reduced.
The 27-year-old died on the B1107 near Thetford golf club when her Ford Ka was in collision with a Volkswagen Golf which had lost control as the driver attempted to avoid an animal.
The two-day Norwich inquest into her death on August 6, 2011, has exposed a series of errors by the trust.
Failures by the ambulance service and a paramedic include:
Inadequate treatment of Miss Barton;
Failure to follow trust guidelines and recognise the serious nature of the accident;
Not providing ambulances and medics quickly enough.
John Holmes, the solicitor representing the trust at the inquest, urged Mr Armstrong to avoid using the word “failing” in his verdict.
But the coroner recorded a narrative verdict yesterday stating: “As a consequence of these failures Catherine Barton’s prospects of survival were substantially reduced.”
He added: “I make that statement boldly and confidently.”
The inquest heard how paramedic Fiona Turner had struggled to deal with the crash and a lack of medical back-up meant Miss Barton was not removed from her car for more than 90 minutes.
Mr Armstrong said: “She (Miss Turner) was clearly struggling with the situation. It is a matter of concern that she did not seek help.
“The scene must have been horrific. It must have been daunting.”
He praised the fire service and police who were the first on the scene and said they did all they could to get more medical assistance.
Firefighters told Miss Turner that Miss Barton’s condition was deteriorating, but their advice did not seem to provoke a response.
“Not only were there individual failings. There were systemic issues as well,” Mr Armstrong said. “Omissions, both systemic and individual, led to a delay.”
He added: “This is a very grave situation. It is also grave from the public’s perspective.”
Mr Armstrong will now take the unusual step of writing to the ambulance trust asking it to review the evidence heard at the inquest and to look at paramedic training and ambulance response times.
He said it would be a “fitting tribute” to Miss Barton’s memory if lessons were learned.
Marcus Bailey, who led the trust’s investigation into what went wrong, said the ambulance crews could have taken Miss Barton out of the Ford Ka 30 minutes earlier.
He told the inquest the tragedy had led to changes to the way the trust responds to accidents.
A new team to oversee where and when the critical care team is sent;
Better communication between the emergency services;
Senior medics in control rooms 24 hours a day to give advice;
More trauma training for staff.
The EDP launched its Ambulance Watch campaign in response to concerns over the service’s performance and health minister and North Norfolk MP Norman Lamb said the death of Catherine Barton reinforced his concerns about the service in the county.
He said: “We know that unacceptable delays are continuing within the county and response times within Norfolk for years now have been below the standard necessary.”
Mr Lamb said he would now write to the Care Quality Commission to make sure it was aware of the case and satisfied with the ambulance’s response to the tragedy.
And South West Norfolk MP Elizabeth Truss said: “The failings that have occurred as identified in the coroner’s report are of major concern. Residents in south west Norfolk and across the whole of the county need to be reassured that action will be taken.”
She added she would be raising the case with the trust.
In a statement yesterday, Miss Barton’s family said they had been left “devastated” by the “tragic chain of events” which had caused “indescribable distress”.
The statement said: “They (the family) are pleased that the coroner has thoroughly investigated the circumstances of this awful tragedy.”
Dr Pam Chrispin, medical director of the trust, said: “The court heard this was a tragic and highly unusual incident involving complex issues and we want to reassure the public that, as the coroner stated, it is not representative of the valuable work our crews carry out in successfully treating hundreds of patients seriously injured in traffic collisions every year.
“As such the trust took this incident extremely seriously and an investigation was launched immediately and a paramedic suspended.
“The trust also passed its findings to the Health and Care Professions Council.”
She added: “We acknowledge the coroner’s comments and recommendations and we are confident that a similar situation would be managed better in 2013 than it was in 2011.”