I made a mistake, says man who diverted ambulance away from dying woman

Peter Richardson, a clinical support desk practitioner, told an inquest he spoke to Ann Walters when he called her back after she phoned 111 for help on December 28, 2014, the day she died at her home in St Piran’s Avenue, Baffins, Portsmouth.

The 61-year-old called for a doctor after feeling breathless at 8.19am in the morning, and an ambulance was dispatched by a call handler, suspecting Mrs Walters’s condition was worse than she suspected.

But when Mr Richardson called Mrs Walters back moments afterwards, following South Central Ambulance Service procedure, he stood the ambulance down when it was just a minute away from her house.

Mr Richardson gave evidence the inquest into Mrs Walters’s death at Portsmouth Coroner’s Court.

Mr Richardson said: ‘She sounded breathless, but I would have expected that anyway, but she also sounded forthright.

‘She clearly stated that she didn’t want an ambulance, she wanted a doctor.

‘Having heard Mrs Walters wanted to be seen by a doctor rather than an ambulance I stood down the ambulance. She thought she had a chest infection.’

Mrs Walters’s son, Lawrence Thorpe, 25, asked Mr Richardson at the inquest: ‘In hindsight, do you believe your decision was wrong?’

Mr Richardson answered: ‘Yes’.

He arranged for an out-of-hours doctor to contact Mrs Walters within one hour, but this did not happen.

Mrs Walters had a long-standing heart condition that was first identified in 1977.

She had an atrial septal defect, commonly known as a hole in the heart.

The inquest heard she repeatedly refused open-heart surgery to fix the problem.

Mr Thorpe said: ‘She just literally didn’t want to be completely opened up.’

Dr Phillip Strike, a consultant cardiologist at Queen Alexandra Hospital in Cosham, said Mrs Walters’s condition had worsened over the years and by the time he last saw her in late 2014 it had become too late for an operation to succeed.

Dr Strike said she was in a fragile condition and said she may have only had ‘weeks to months’ to live.

Dr Strike said a cardiac arrest or a change in the rhythm of her heart could have caused her death at any time.

He said: ‘She was a phenomenally high risk of rapid or sudden death.’

Dr Strike said he doubted the ambulance crew could have saved Mrs Walters if they had gotten to her. ‘It seems unlikely that this would have been remedial.’

She was found dead in her front room about 6pm that day by Mr Thorpe.

Mr Thorpe, who lived in London at the time, had been staying with his mum over Christmas and had last seen her about 2.30am that morning when he came home after visiting a friend.

Mr Thorpe said: ‘She was in the front room watching television. She seemed all right then.’

They both went to bed soon afterwards and Mr Thrope spent the day upstairs sleeping and watching films in his bedroom. He did not see his mum until he came downstairs and found her lying on the floor.

He called an ambulance, which arrived at 6.10pm and found that she had been dead for some hours due to ‘congestive cardiac failure subject to an atrial septal defect’.

The inquest heard that call volumes to Scas had been extremely high over the Christmas break, and was under ‘extreme pressure’.

Scas conducted an investigation into the case and found the decision to stand down the ambulance had been ‘flawed’.

The inquest heard that response procedure was changed nationally on January 5 this year so that ambulance dispatches that originate from 111 calls cannot be reassessed, but this change was not a result of Mrs Walters’s case.

(Proceeding)