Steve Cooke
8 Aug 2021 · Coroner Sonia Hayes · Mid Kent and Medway
The coroner's concerns
1. ambulance dispatched to wrong address
“Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr [name redacted] not being located”
2. inadequate call handling
“The call handler when speaking to Mr [name redacted] ex-partner: (i) EOC terminated the call within 62 seconds - this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr [name redacted] current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr [name redacted] could not be located there and did not listen to or give sufficient time for Mr [name redacted] ex-partner”
3. failure to verify address
“(2) Mr [name redacted] was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr [name redacted] could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr [name redacted]. Mr [name redacted] gave the address as Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr [name redacted] lived. (iii)”
4. premature call termination
“(i) EOC terminated the call within 62 seconds - this very brief given the serious nature of the query to locate a missing sick patient”
5. incomplete communication
“(ii) did not give a complete explanation of the reason for the call”
6. missing address request
“(iii) did not ask for Mr [name redacted] current address”
Responses
2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published.pdf ↗· South East Coast Ambulance Service
Stated action · one to two weeks
“They have looked at two issues: 1. Our process for establishing the address to which to send an ambulance It has been identified that whilst there was in place clear instruction to 999 call handlers that the caller must give the address rather than the handler suggesting it, this instruction had not been replicated in the 111 system. This is being remedied.”
Stated action · one to two weeks
“Operational Bulletin has been written to update and improve our process when crew on scene are not able to locate the patient. I attach a copy. It will be noted that the process involves the escalation of the incident to a team leader who will listen again to the original call to verify the address, search our records for any previous calls from the same telephone number and identify any sources of further information such as next of kin or a careline. If the team leader can locate a family member or”