Ffion Louise Jones · Prevention of Future Deaths report

A Coronial investigation was commenced into the death of Ffion Louise Jones concluding at the end of the inquest which I conducted on 12th and 13th September 2019. The conclusion was a narrative conclusion and the medical cause of death was 1a. hypoxic ischaemic brain injury; 1(b) out of hospital cardiac arrest; 1(c) addisonian crisis

These were recorded as :-

Ffion Jones died as a result of a crisis of Addison’s disease following a collapse at the surgery of her General Practitioner. Despite requests for urgent attendance, there was no ambulance attendance for almost 1 hour following her General Practitioner’s emergency call. The call was not escalated to the clinical support desk as it should have been. Escalation would have been likely to have led to ambulance attendance prior to Ffion arresting, in which case Ffion would have been resuscitated and quickly transferred to hospital. It is likely that she would have survived.

The narrative conclusion which I returned was:

Ffion Jones died as a result of an Addisonian Crisis She suffered a seriously damaging arrest at her General Practitioner’s surgery while waiting almost one hour for ambulance service assistance that had been requested urgently, but had been delayed by a failure to escalate her case to the clinical support desk.

The Inquest focused upon:-

a. The fact that Ffion presented to her GP shortly after 14.00 on 7.12.16 in a severely unwell state such that her GP quickly decided that she needed urgent transfer by ambulance to hospital
b. The GP initially sought to effect this using a number which the ambulance service had informed her could allow health care professionals to obtain an emergency response
c. The GP then telephoned 999 as directed and sought to stress the urgency of the requirement for ambulance attendance
d. The call was subject to standard questioning and the response assessed by the MPDS prioritisation tool and graded amber 2
e. Her call was not referred to the clinical support desk as it should have been
f. Had this occurred the response would have been upgraded from amber 2 to amber 1
g. The clinical support desk operates a referral system which includes supporting members of the public and operates a queuing system
h. There remains no dedicated means for an external health care professional to have urgent access to a discussion with a clinical member of staff to ensure that their assessment of their patient’s clinical need is fully, properly and quickly conveyed to the ambulance service, to ensure the proper assessment of the urgency of the response.

(1) The Improvement plan provided at the Inquest did not include any consideration of the specific shortcomings in service provision leading to Ffion’s death and the witness speaking to it was unable to address these issues

(2) There remains no dedicated means for an external health care professional to have urgent access to a discussion with a clinical member of ambulance service staff to ensure that their assessment of their patient’s clinical need is fully, properly and quickly conveyed to the ambulance service, and thus that there is a properly informed assessment of the urgency of the response.

(3) There is a real risk of the recurrence of the circumstances leading to Ffion’s death