Mark Hemmings called the emergency services begging for an ambulance while in severe pain due to gall stones – but was told by the 999 operator: “You could try a warm bath but if you collapse, become unconscious, unresponsive, faint, cold or clammy it’s 999.”
Both the emergency line operator and a doctor refused to send an ambulance to his home, and told him to take a warm bath instead, an inquest heard.
The Mirror reports: – Mark Hemmings died just 30 minutes after he eventually arrived at hospital – two days after he first dialled 999.
The 41-year-old had been struck with the painful gallstones – which could have been cured with a routine operation.
Astonishingly, his increasingly desperate pleas for an ambulance on Good Friday last year were met with little response despite him calling 999 and speaking to an out-of-hours GP on the same night.
He received no medical treatment over the Easter weekend until his carer eventually found him writing in agony on the floor of his home on April 1, and called 999.
On this occasion, an ambulance did attend and took Mr Hemmings to University Hospital of North Staffordshire where he was diagnosed with pancreatitis. But minutes after he arrived Mr Hemmings died.
A post mortem revealed his gallstones had blocked his pancreatic duct and triggered a fatal heart attack.
This week an inquest heard Mr Hemmings was unable to drive and spent his final two days in agony as his organs slowly failed.
During the hearing at North Staffordshire Coroner’s Court, a specialist from the University Hospital of North Staffordshire said that if he had been taken to hospital sooner he would probably have survived.
Consultant Damien Durkin blasted a series of computerised questions used by ambulance controllers to decide if callers need help and out-of-hours doctors who failed to “ring alarm bells”.
The inquest heard harrowing recordings of Mr Hemmings’ desperate pleas to 999 handlers and a GP urgent care unit.
During one seven-and-a-half minute call, Mr Hemming can be heard groaning in agony while he begs the operator three times to send an ambulance but is refused each time.
At one stage the dispatcher even told him to call back if he fell unconscious before dismissing his moans as a stomach ache.
Eventually operator Heidi Nicholls said: “From what you’ve told me you don’t need an ambulance.”
Mr Hemmings replied: “But I’m in agony.”
Call handler Miss Nicholls said the questions she was told to ask Mr Hemmings by a computerised algorithm system ruled he did not need an emergency ambulance, and added: “We cannot override this and although there are paramedics in the control room for us to ask, I would not think the system would come up with the wrong answer.”
He was then advised to take a warm bath to ease the pain and the case was passed on to an out-of-hours GP.
Miss Nicholls told him: “You could try a warm bath but if you collapse, become unconscious, unresponsive, faint, cold or clammy it’s 999.”
Mr Hemmings waited 90-minutes before Dr Sri Sukhavasi called him back, and told the medic he was in excruciating pain and about to pass out. But during the three-and-a-half minute conversation, the doctor refused to attend his home and instead told Mr Hemmings – who lived alone and could not drive – to come to the surgery himself.
When Mr Hemmings, who suffered mental and physical problems, failed to turn up for the appointment his records were marked ‘did not attend’ and no further checks were made on his condition.
The inquest heard the tragedy happened over the same weekend the GP out-of-hours service was passed from North Staffordshire Urgent Care (NSUC) to a new provider based in the north of England.
Dr Sukhavasi told the hearing: “I had no doubt he needed to be seen straightaway but I thought it would be more effective for him to come in to the base.
“I did not offer to visit because we had an enormous amount of work that night and it is better to examine patients in a clinical setting than people’s homes.”
“I did not call an ambulance because I knew he had already been told one was not necessary.
“In hindsight when he said he was in pain I should have explored further what was causing it.”
Mr Hemmings was eventually found by his carer Yasir Mohammed, who discovered him passed out on the floor of his home on the Monday morning.
Mr Mohammed, from the Brighter Futures mental health charity, dialled 999 again and this time a response car and ambulance were sent but it was too late. But even during the 999 call, the handler got Mr Hemmings’ name wrong and appeared reluctant to send an ambulance despite him complaining of chest pains.
West Midlands Ambulance Trust medical director Dr Andrew Carson said six of Britain’s 11 services had the algorithm system which had been used on millions of people.
He said: “Its conclusion to have the case assessed by a GP within two hours was correct and we trust that the other organisation will deal with it.”
Reserving his verdict until November 14, Coroner for Stoke-on-Trent and North Staffordshire Ian Smith said: “He fell through gaps in the system because he was not pushy enough.”
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