A family were left devastated after learning a machine that could have saved their mum was less than 200 yards away - and the 999 call handler failed to tell them. Sharon Beales, 56, went into cardiac arrest while surrounded by relatives at her home earlier this year.
The carer had been watching a movie when the colour drained from her face and she started foaming at the mouth, her family say. One of her sons called 999 and a South Central Ambulance Service (SCAS) call handler asked him about an "AED", it is claimed.
But relatives allege the person on the phone did not clarify what this was: an automated external defibrillator. Sharon's son says he thought the call handler was talking about an IED - an explosive device - and, in the confusion, the defibrillator was forgotten about.
In fact, a device - which can shock the heart back into its normal rhythm - was located just 160 yards away in an old phone box. SCAS admitted the call handler "did not advise the family to access their nearest community defibrillator".
And an inquest heard that the delay during this crucial period may have contributed to the gran's death in hospital. Sharon was taken to Royal Berkshire Hospital where she was induced into a coma, and her life support was withdrawn on January 29.
Daughter Yasmin Maskell, 28, said: "Our mum was such a wonderful woman. We're absolutely devastated, and we don't want this to happen to anyone else. There was a failure that should never have happened, and we need to make sure it doesn’t happen again.
"There needs to be a better system for the public to know how to use defibrillators and an easier way for the public to access them. Even if you know there is one, you can’t access it without getting the code from the NHS."
Mum-of-six Sharon went into cardiac arrest in her lifelong home in Kintbury, where she was living with husband Laurence Beales, 65, just before midnight on January 18. He called out for two of their sons, who rushed downstairs to find their beloved mum grey and cold.
One carried out CPR for 11 minutes, while another called an ambulance. The family claim they were then asked if there was an "AED" nearby after dialing 999 - but they didn't know what that meant so said they didn't think so.
And the call handler didn't flag there was a defibrillator in a disused phone box just two minutes away, SCAS said. Yasmin claimed: "It's crazy - the term AED didn't mean anything to my brother.
"In his shock and while giving CPR to our mum, he thought she was asking about explosives, IEDs. They should use the word defibrillator, that's how we all refer to them - and the coroner agreed.
"It's a problem with the NHS system too, she needed to press a button to see where the defibrillator was but she didn't know to do that. And she shouldn't need to know - the system should just flag up if there's a defibrillator nearby. The coroner said that too.
"That poor girl will be feeling awful, but she shouldn't have to. There was a gap in the system and shouldn't be. I would urge everyone to make yourselves aware of the location of defibrillators and how to use them."
Yasmin claims her mum would have got a defibrillator shock in four minutes if the family had been told about the local machine. Instead, she ended up waiting 14 minutes to be shocked by paramedics - a crucial period of time.
Dr Matthew Frise, a doctor in the intensive care unit at Royal Berkshire Hospital, told an inquest into Sharon's death that an earlier intervention could have been life-saving. He said: "The key intervention in that situation is defibrillation; it reduces the amount of time the patient spends without oxygenated blood getting to the brain.
“Had a defibrillator been provided several minutes sooner it would have offered a better chance of survival."
He added that it was impossible to know for sure whether the outcome would have been changed. Coroner Heidi Connor asked SCAS to investigate the situation and have a full report by October 31.
And husband Laurence said: "We are all heartbroken. Sharon was always a giver, working 15-hour shifts and she's donated her organs. This is such a sudden and painful loss, and could have turned out differently. The defibrillator was just around the corner: if only we'd known."
SCAS said: “We would like to express our sincere condolences to Ms Beales’ family for their loss. The call taker managed many of the aspects of the call well, including providing essential CPR instructions.
"However, they did not advise the family to access their nearest community defibrillator. Although the coroner stated this was unlikely to have changed the very sad outcome, providing callers with advice regarding community defibrillators is something we expect our call handlers to do, if they are available.
"Whilst this advice was not given in this case, it must be remembered that a call taker needs to provide instructions regarding basic life support (CPR), gather information regarding the patient’s location, so that an ambulance can be dispatched and deliver advice regarding the location of a community defibrillator, all in the first few seconds of the call, which is a challenge.
“Following Ms Beales’ sad death, we are undertaking a review to ensure any learning is identified and implemented to prevent a similar occurrence from happening again.
"This review includes engaging with NHS Digital regarding the advice presented to call takers during the call. Details of this review and its findings will be reported back to the coroner at the end of this month. The family will receive a copy of this correspondence.
“Importantly, we are also extensively supporting national campaigns to raise awareness of the importance of public knowledge of defibrillator locations including promotion of www.defibfinder.uk. a website created by the British Heart Foundation in collaboration with SCAS which uses data from national defibrillator network ‘The Circuit’ to help people find information about their nearest defibrillators.”
Sharon's cause of death was recorded as hypoxic brain injury caused by cardiac ventricular arrhythmia.
