AN NHS out-of-hours service has come under fire after a ‘perfect storm’ of errors led to the disastrous death of a great-grandmother-of-two.
Partnering Health Limited (PHL) has run the Hampshire doctors on call service for three years.
The fifth of December was pretty much as disastrous day for the out-of-hours service. Everything that could have gone wrong did go wrong.Portsmouth and south-east Hampshire coroner David Horsley
On December 5, 2015 the group was contacted by the worried son of Portsmouth pensioner, Myra Collins.
The 76-year-old diabetic, of Australia Close, Landport, was having difficulty breathing and had been vomiting.
Operators on the 111 non-emergency helpline told her son Glenn, 48 that a doctor would be dispatched arrive at her home ‘within six hours’.
But a catalogue of delays, IT system failures and blunders by call handlers meant a doctor did not turn up until the next day – eight hours after Mrs Collins had died.
At the inquest into the grandmother’s death, PHL’s deputy medical director revealed a damning series of slip-ups on the day she died.
Mrs Collins’ devastated daughter Beverley Casey wept as Dr Mike Johns read out extracts from the findings of a serious incident review.
Dr Johns told the court that the IT system at PHL’s base at Cowplain Centre, in London Road, Cowplain, had been given a major overhaul.
But said none of the staff had been trained to use it.
As controllers battled to understand the new system, a backlog of calls built up, causing delays to spiral.
‘It was a complete disaster,’ he told the court.
Other errors revealed in the review were:
n A shortage of on-call doctors to cover the county.
n Batteries on new mobile computer tablets kept failing, forcing doctors to return to the base to charge the devices.
n Call-handlers ‘completed an unsafe act’ and failed to properly assess Mrs Collins’ most serious symptom.
n Doctors lost keys to their cars, adding to delays.
n Lack of communication from dispatchers to doctors.
Portsmouth and south-east Hampshire coroner David Horsley said: ‘December 5 was pretty much a disastrous day for the out-of-hours service.
‘Everything that could have gone wrong did go wrong.’
Mrs Collins died of cardiac arrest and was found by her son at 2.07am on December 6
She was pronounced dead by paramedics, at 2.13am.
Pathologist Dr Adrian Al-Badri told the court Mrs Collins had a range of ailments, including a weakened heart and kidneys.
But he said if she had been taken to hospital earlier, she would have had an increased chance of survival.
Penny Mordaunt, Portsmouth North MP, was shocked by the blunders and said: ‘While what has been described is a perfect storm of errors and faulty IT, what this also points to is management failure where so many new and untested systems were in operation at the same time.’
Portsmouth South MP Flick Drummond said: ‘I know that the CCG have had concerns for some time about PHL according to their board minutes and I hope that they are now satisfied that PHL have improved their service as we cannot have another incident like this one.
‘My heart goes out to Myra Collins’ family as they have been let down badly.
‘I will be asking the Care Quality Commission to inspect this service again to ensure that the service has improved so that other families do not have to go through this heartache.’
Dr Johns said PHL – which serves 1.7m people in Hampshire – had made changes to avoid future disasters.
‘There’s no getting away from the fact we were hours and hours late and we’re extremely sorry for that,’ he added.
Daughter says she is devastated after mum’s death
‘NO MATTER how much they apologise it will never bring my mum back’ – these are the heartbreaking words of a daughter whose mum died while waiting for a doctor to help her.
Devastated Beverley Casey has said she will never forgive care firm Partnering Health Limited for the blunders on the day her mother, Myra Collins, died.
Beverley, 45, of Somers Town, said: ‘What happened is absolutely disgusting.
‘They (PHL) say they’ve improved but that’s never going to bring our mum back. Our lives have been ruined.’
Mrs Casey broke down in tears as a report into PHL’s errors on December 5 was read out during her mother’s inquest, at Portsmouth Coroner’s Court.
Mrs Casey said she had never been made aware of the review by the service – something that coroner David Horsley urged PHL to change in the future.
Paying tribute to her mother, Mrs Casey added: ‘She was a funny mum with a devious sense of humour.
‘We loved her all so much.’
Mrs Collins leaves behind two great-grandchildren, eight grandchildren and four children.