A woman died after waiting over 16 hours for an ambulance - leading a coroner to slam NHS reliance on computer systems. Before she became fatally ill doctors knew 44-year-old Sandra Finch was at risk by taking prescribed antibiotics following a dental procedure, upping the insulin required to manage her type 1 diabetes.
However, healthcare services triaging via “rigid” computer systems meant Miss Finch was found dead in her flat 16 hours after calling 999. A Prevention of Future Death Report from the South Staffordshire Coroner stated that a real-life clinician would have declared Miss Finch a medical emergency, meaning she “would not have died when she did.”
Assistant Coroner Emma Serrano said more people will die if nothing changes. Following the dental procedure infection Ms Finch’s glucose levels started to rise, signalled by a pump that pings off an alarm to correct the dose.
The next day Ms Finch called 999, telling handlers she was sleepy, her glucose was high and she had been vomiting, adding that she could not find her blood sugar test kit. When Miss Finch called emergency services at night a computer system incorrectly categorised her as category three - symptoms that are urgent but not life-threatening and require an ambulance within an hour.
It was listed that a clinical review was required by the clinical validation team before paramedics could be dispatched, but no time limit was given for the assessment. The inquest heard that the West Midlands Ambulance Service was also understaffed meaning ten hours went by before someone called her.
Ms Serrano said a clinician would have accurately ranked her a category two emergency that requires an ambulance in 18 minutes. At 7.22am the next morning, ten hours after Miss Finch called emergency services, a clinician called her back and she didn’t pick up.
It took five more hours for her case to be escalated from category three to category two, at 12.47pm. On arrival, paramedics found her dead in her property at 1.08pm on December 5 2021. She had died from ketoacidosis.
Summarising the inquest's findings, Ms Serrano said: “Clinical opinion disagreed that category three was the correct categorisation. It should be have been a category two. Evidence was heard that the pathway had to be followed rigidly so a computer could decide the category, but accepted that a clinician listening to the answers may well have made a different decision and given the call a category two marking.
“The view of clinicians was that had the ambulance been dispatched within the accepted time limit for a category three ambulance, Sandra Diane Finch would not have died when she did. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.
“That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention.
"Clinical opinion in agreement that this was, but the rigidity of the pathway meant it was categorised incorrectly. That the use of an assessment team, to asses a category three ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.”
The report was sent to West Midlands Ambulance Service, NHS England, electronic healthcare providers Medtronic Ltd and the family of Miss Finch. West Midlands Ambulance Service’s Chief Executive Officer responded that the reliance on computers was part of a pilot scheme to alleviate the burden of staff shortages during the pandemic.
The CEO, whose name is redacted, said: “In July 2021, during a period of significant demand on the ambulance service as the NHS adjusted to the challenges of the coronavirus >Covid pandemic and changing lockdown requirements, the Trust implemented a pilot to undertake the clinical triage of category three and four incidents to better manage patients to appropriate outcomes and reduce the pressure on emergency departments.
“All category three and four incidents, except for a predefined list of exemptions now go directly to the clinical validation team. The team undertake a clinical triage, supported by the NHS Pathways triage tool for clinicians, to determine the most appropriate outcome for the patient based upon their clinical knowledge and experience.
“The Trust now aims to contact category three and four patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category. Patients waiting more than 120 minutes, and each 120 minutes thereafter, are highlighted for further a risk assessment by the clinical navigator.
“Throughout 2023-23, the clinical validation team reviewed 179,695 category three and four patients. Sixty-four per cent of patients were referred to alternative services or provided with self-care advice to manage their symptoms at home.
“When reviewing the last six months to May 2023, only 9.9 per cent of patients referred to alternative services or given self-care advice recontacted the Trust through 999. Often, the reason for recontacting was due to a failed referral pathway and not through worsening symptoms
“May I once again please pass on my sincere condolences to the family of Mrs Finch.”
