Woman died after doctor didn't realise what he could do on 999 call

A woman died after a doctor didn't realise he could escalate a 999 call. Amanda Gainford waited three hours for an ambulance after seriously injuring herself following a row with another patient at a mental health unit.

The 52-year-old was detained under the Mental Health Act on September 13, 2022, and she was initially on the Harington Ward before being transferred to Brunswick mental health ward at the Broadoak Unit in Broad Green on October 5, 2022. A prevention of future death report published by Kate Roberts, assistant coroner for Liverpool and Wirral, on Thursday, October 24, following the conclusion of an inquest.

In the report, Amanda was described as being in poor physical health which made her "more vulnerable to injury and trauma". She used a walking frame due to a cast on her leg for an injury caused following a car crash several years before, as she waited for her leg to be amputated.

During her time on both wards at the hospital, Amanda was assessed for a psychotic disorder. The report said her risks came from falls due to immobility, aggression and retaliation of others.

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On October 24, 2022 the report said Amanda began arguing with another patient in the corridor which led to them pushing each other. Amanda picked up her walking frame before moving towards the other patient, but she connected with the doorframe, leading to the walking frame hitting her abdominal area.

She continued to go towards the other patient but they extended their leg which hit Amanda in her lower abdomen. The report said she then proceeded to harm herself as she banged her head on the bathroom floor and again in the bedroom, which reopened a cut on her head. Observations were taken at around 5pm which found she had low blood pressure.

In her notes, Kate Roberts, assistant coroner for Liverpool and Wirral, she said: "Advice was documented in the RIO notes but it was unclear as to the nature and extent of the advice given to health care staff supporting Amanda thereafter.

"It was clinically appropriate given Amanda’s condition to give intravenous fluids and an ambulance should have been called, neither action was taken and there was a missed opportunity which may have possibly made her injuries survivable.

"Further blood pressure monitoring was recorded at around 8pm with no records of checks otherwise. Amanda’s blood pressure remained low and she presented as pale and jaundiced."

A further assessment by a doctor took place at 8.15pm before she became unresponsive and an IV line was administered. An ambulance was called at 8.24pm, by which time Amanda's low blood pressure meant her injuries were more likely than not unsurvivable.

Another two calls were made at 8:42pm and 10:04pm to the North West Ambulance Service, with the operator deeming it a category two incident. Calls to 999 requesting ambulances are placed in one of four categories aimed at ensuring all patients get the right response.

Category one is classed as an immediate response to a life-threatening condition, category two is a response to a serious condition which may require rapid assessment and/or urgent transport, category three is an urgent problem which requires treatment and transport to an acute setting and category four is classed as a non-urgent problem.

Amanda was taken to Whiston Hospital by ambulance at 11.14pm where she suffered a cardiac arrest. She was transferred to Aintree University Hospital and she was discharged from the Mental Health Act detention.

Amanda died on November 4, 2022 at Aintree University Hospital due to multiorgan failure due to splenic laceration and liver cirrhosis. The prevention of future deaths report said the laceration was more likely than not from either the deliberate action with the walking frame or the deliberate falls to the floor.

The matters of concern for the coroner was that the doctor was unaware they had the ability to escalate the category of the incident from category two to category three, which would have affected the time Amanda would have waited for an ambulance.

Ms Roberts wrote: "The NWAS witness gave evidence to the court that had the doctor disagreed with the category 2 classification of the call or sought to escalate his clinical concerns regarding a patient, that he had the ability to challenge that and to request a review by a clinician available to NWAS.

"The doctor was unaware that he had the ability to challenge the call handler categorisation and to seek a review by a clinician at NWAS, at which point the nature and seriousness of Amanda’s condition could have been further reviewed and clearly understood.

"At a further course attended subsequently by the doctor he advised that of 50 doctors in attendance, only one was aware of the ability to escalate concerns regarding a patient and the categorisation of a 999 call to the ambulance service and subsequent response time.

"It appears that this is an important fact unknown by many clinicians which would enable a clinician to clinician review of a critical patient and the use and dispatch of ambulance resources to prevent the loss of life in critical cases which are not automatically categorised at the highest level of response."

The report was sent directly to NHS England with the coroner deeming action must be taken to prevent future deaths. An NHS spokesperson said: “NHS England extends its deepest sympathies to the family and friends of Amanda Gainford. We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.”