The Telegraph
LONDON — An investigation into a woman’s death has exposed a catastrophic decision by ambulance chiefs which may have cost hundreds of lives.
The blunder arose when call centre staff were not warned of flaws with a computer system that prioritises emergencies before dispatching ambulances.
Bonnie Mason, 58, fell down the stairs and died from a head injury after 999 controllers in Suffolk failed to identify her situation as “life-threatening”. Her family could not understand why it took so long for an ambulance to be sent to the dying nurse, whose husband had explained that she was unconscious, and breathing abnormally after falling more than 12ft last May.
An investigation by The Sunday Telegraph has uncovered a critical danger placed in the software used by most ambulance services. For years, 999 calls in life-threatening situations like Mrs Masons’s were accidentally “downgraded”, with call handlers told not to send the most urgent response.
While some services spotted the risk, ordering operatives to override the computer’s orders manually, five of England’s 12 ambulance trusts did not allow call handlers to upgrade such calls. They include the East of England ambulance service, which covers Suffolk and which only identified the risk after Mrs Mason’s death.
The danger in the system was created by the country’s most senior ambulance officials as they altered the program used by most control centres in an attempt to manage demand for 999 services.
American-designed
Most ambulance services use an international computerised system designed in America. In the US version, a fall of more than 6ft receives the maximum priority response. However, the government committee which governs its use in this country decided that such cases should be deemed less urgent, and excluded from an eight minute category A target response time.
In doing so, they created a potentially lethal flaw in the system. It meant that if a call involved a fall of more than 6ft it was designated a lower priority, a category B response, despite the presence of life-threatening conditions which were supposed to receive the most urgent category A response.
As a result, Mrs Mason lay unconscious for more than 38 minutes. The first ambulance sent to her home in the village of Eye, Suffolk, was diverted to attend to a drunk woman who had fallen on a pavement 22 miles away in Thetford, Norfolk. Because the inebriated woman had fallen at ground level, her situation was prioritised over that of Mrs Mason, who was close to death by the time paramedics arrived. The East of England ambulance service, which also covers Bedfordshire, Cambridgeshire, Essex, Hertfordshire and Norfolk, said its operatives were instructed never to “override” the advice of the automated system.
The trust said it received about 6,000 calls a year relating to patients who have suffered a fall, and are also unconscious or not breathing normally.
After Mrs Mason’s death last May, the service contacted software manufacturers to express their concerns about the risks the system posed to such patients, who would only have been categorised as category A if they had stopped breathing, or had visible injuries to specific parts of the body.
The Department of Health said that ambulance trusts should have trained their operatives to “upgrade” falls manually if a lifethreatening symptom was identi-fied. But five of the 12 services in England - North West, West Midlands, Yorkshire, East of England and the Isle of Wight which between them cover a population of 25million - told this newspaper that they instructed call handlers to never override the automated response.
Dr Jeff Clawson, the founder of the software technology, which is used by 3,000 emergency services across the world, said their stance betrayed a “profound misunderstanding” of how the system should be safely operated.
If any 999 call generated conflicting advice, handlers should choose the maximum priority response, and not allow the computer to “lock on” to the first answer, said Dr Clawson, the managing director of Advanced Medical Priority Dispatch System.
Unknown number
Peter Walsh, the chief executive of the charity Action Against Medical Accidents, said: “Who knows how many people this could have harmed and how many may have died? Given the volumes of 999 calls involving people who have fallen and are unconscious, there is a risk that thousands were affected. Who knows how many might have died; it could be hundreds, but even if it’s just one needless death, we need a full review to establish what went on”.
In June, an inquest will explore whether the delays receiving care were responsible for Mrs Mason’s death. Her father-in-law, Dr Andrew Mason, a doctor who specialises in trauma airway management, believes she might have been saved if help had arrived sooner.
Dr Mason, who trained paramedics across East Anglia for more than a decade, uncovered the problem in the system operated by East of England ambulance service.
He said: “I have worked in this field for my whole career, yet it was almost impossible to believe what had happened. To find out that ambulance services across the country were operating in this way for years is terrifying; hundreds more people may have died.”
His son Tom said: “Bonnie was the love of my life and I am struggling to manage without her. We want to find out not just how this happened to her, but how this system was allowed to operate like this for so long.”
Mike Penning, the Tory health spokesman, said: “This is absolutely terrifying. To find out that this has gone on for 10 years, without anyone taking responsibility for it. If half of the trusts spotted the problem, and told staff to override the computer, how can the others explain themselves? Why did the Government not give clear advice when the risk was identi-fied? “We will be writing to the secretary of state to demand a full inquiry. We would also want the regulators to investigate this”.
The DoH said the risk for patients who suffered a fall had been eliminated from the latest version of the software, which most trusts introduced last year.
In the new system, patients who have suffered a fall of more than 6ft are still category B, but the question is asked later in the script set for control room operatives, so that it cannot “override” the most serious conditions.
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