Man, 77, died from sepsis after eight-hour wait to get into hospital
- Credit: Archant Norfolk
Systematic failures at the region's ambulance trust may have caused a 77-year-old man to die of sepsis, it has been revealed.
Christopher Williams, of Barnham Broom, died on January 26 this year and an inquest in May heard how this was caused by multiple organ failure, sepsis, and an infected wound after an operation.
But area coroner for Norfolk, Yvonne Blake, has now slammed processes at the East of England Ambulance Trust (EEAST) as "unacceptable" and said they placed other patients at risk of death.
In a report released by Ms Blake it said Mr Williams had an operation on his foot on January 19, to remove a screw from a previous surgery which was becoming infected.
But two days after the operation he was in severe pain and his GP was concerned about a serious condition called cauda equina, where the spinal nerve roots are compressed.
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An ambulance was called and a bed was arranged at the Norfolk and Norwich University Hospital (NNUH) but EEAST told the GP it could take the crew up to four hours for it to arrive.
An hour later when EEAST called back to check on the patient, the call handler did not escalate the call when told his condition was worsening and an incorrect algorithm was used which meant the wrong questions were asked.
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Finally, five hours later, a 999 call was made to say Mr Williams was not alert and had difficulty breathing. A crew arrived within 20 minutes but when Mr Williams was taken to hospital he had to wait in the ambulance outside for three hours, even though a bed was available to him - unknown to paramedics.
The next day, his condition worsened and it was established he had sepsis. Despite being admitted to the high dependency unit, he died on January 26.
Ms Blake said she was concerned about how long the ambulance took to arrive, the call handler not escalating the call, and how Mr Williams was not immediately transferred to a hospital bed.
The report said: "[EEAST's] business continuity manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm".
In evidence it was found the trust "did not know" why the call handler did not escalate the call or why she used the wrong algorithm.
And it was also not know why the paramedic crew did not know a bed had been arranged.
A manager said during the inquest he had not made any enquiries about this.
Ms Blake said: "Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident and it appears that there are systematic failures without your organisation which should be addressed."
A spokesman for EEAST apologised to Mr Williams' family and offered their condolences.
He said the trust had asked for triaging software to be changed, and call handlers had been supported "in recognising and escalating deteriorating patients by using training, one-to-one sessions, and developing specific telephone screening tools for sepsis".
They were also working more closely with hospitals and had secured funding for 330 more staff.
In a notice posted in this newspaper after Mr William's death, it said he was survived by wife Amanda and children Bryony and Hugh.