Three patients died after failings that occured during ambulance pilot scheme

Adam Frere-Smith, 48, who died after failings by the East of England Ambulance Service Trust. (Image: Archant)

The deaths occurred during a year-long scheme which was designed to reduce unnecessary patient trips to A&E departments.

But an inquest was yesterday told how three patients died – and a fourth needed intensive care – after serious failings by paramedics and GPs who took part in the trial.

One of those patients who died was 48-year old Adam Frere-Smith, of Cromer, who suffered a fractured skull and subdural haemorrhage, but was not taken to hospital because a paramedic thought it was a 'minor wound'.

The decision not to take Mr Frere-Smith to hospital was made after the paramedic spoke to a GP based in the ambulance headquarters - despite it clearly breaching NHS guidelines.

That conversation was made possible because of a pilot trial introduced by East of England Ambulance Service Trust (EEAST) last year.

The scheme gave paramedics the chance to call GPs based at ambulance headquarters to discuss treatment options for patients while at the scene.

It was hoped this would ensure more patients were given the correct treatment and not taken to busy hospitals unnecessarily.

But at the inquest Dr Tom Davis, deputy medical director at EEAST, said the trust had identified three patient deaths and another patient needing intensive care following discussions between GPs and paramedics using the pilot scheme.

He admitted the organisation 'did not have the oversight to ensure the service was understood by everyone and used appropriately by everyone'.

The trust has discontinued the trial with a spokesman adding it was reviewing the scheme.

Mr Frere-Smith's family said after the inquest, held at Norfolk Coroner's Court, that they were shocked to hear his death wasn't an isolated incident during the trial.

Details of the other cases have not been made public.

Johanna Thompson, assistant coroner for Norfolk, said she had been given assurances by EEAST that any new such scheme would be 'heavily monitored'.

At the inquest it also emerged that neither the paramedic or GP involved in the failings of care for Mr Frere-Smith have completed a review of the incident.

And parts of the trust's 'action plan' - drawn up after EEAST carried out its internal investigation - are yet to be implemented, which has angered Mr Frere-Smith's family.

Following the inquest EEAST must complete the action plan by mid-August.

Ms Thompson said: 'The ambulance trust has accepted that the assessment of Mr Frere-Smith was not thorough and that his head injury was not fully explored by the paramedic or GP.

'I shall require the ambulance service to provide an update as to the progress of the action plan and that the family be kept updated.'

Dr Tom Davis, deputy medical director of EEAST, said after the inquest: 'The trust recognises that mistakes were made in the care of Mr Frere-Smith, who should have been taken to hospital.

'We have apologised to the family, an apology we reiterated in the coroners court today.

'We have carried out a full investigation to identify the mistakes that were made and to put in place actions to improve the service in the future.

•Have you had a good or bad experience of our ambulance service? Email nicholas.carding@archant.co.uk