Sabrina Stevenson · Prevention of Future Deaths report

The investigation into the death of Sabrina Stevenson concluded at the end of the inquest on 23 January 2015. The conclusion of the inquest was narrative (Copy attached).

Sabrina Stevenson died on 16 December 2012 from a ruptured ectopic pregnancy; she was aged 28. That morning she began to suffer from abdominal pain, diarrhoea and vomiting; she went on to suffer an episode of collapse. Her flat mate called for an ambulance at approximately 6pm.

I have set out below my findings of fact based on the evidence heard, including an independent expert opinion from Professor ████████

The initial triaging of the 999 call prompted a clinical call-back, rather than ambulance attendance; this represented an ‘under-triaging’ of Sabrina’s condition. The call-back did occur within the expected time-frame and retriaged Sabrina as requiring an ambulance to attend within 30 minutes.

Demand for ambulances was higher than had been predicted for the time of year. The individual who undertook the call-back assessment did not have access to the current response times for ambulances, which were exceeding the intended 30 minute time-frame.

A further call-back occurred after the time-frame for attendance had past; this call was not made by a clinician and did not provide sufficient safety-net advice to Sabrina. There was also no reassessment of the call categorisation, nor (in the alternative) automated recategorisation at this point.

One hour after the initial 999 call an ambulance dispatch was attempted; however, this vehicle was part of a pilot scheme which did not accept patients with diarrhoea and vomiting. As such, the dispatch request was turned down. I concluded that the pilot scheme was appropriately instituted and the non-attendance was in-line with the clinical guidance. This conclusion was in contradistinction to the ambulance Trust’s own internal investigation, which was later recanted by the Trust in evidence at the inquest.

Three further ambulances were attempted to be dispatched to Sabrina but were diverted to higher priority calls. An ambulance crew first attended Sabrina approximately two hours after the initial 999 call.

The focus of this crew was insufficient regarding the potential for serious abdominal pathology as the cause for an initial low blood pressure and raised heart rate. Hypovolaemic shock was not considered in a meaningful way and too much reliance was placed on Sabrina apparently reporting that she had a contraceptive implant in place. This was contrary to the evidence of her GP, who stated that it had previously been removed. Sabrina presented the crew with a difficult situation regarding her pain management and also the assessment of her capacity to make treatment decisions. There was no formal documented assessment of her capacity.

Sabrina suffered a further episode of collapse, which was described by the independent expert as the ‘last possible point at which it would be defensible to delay’ extraction out of the flat. A second ambulance crew was requested to assist with extraction.

There was a failure of appropriate handover to the second crew. They persisted with an inappropriate assessment focus and insufficient consideration as to whether Sabrina had lost capacity to make treatment decisions. The two crews also failed to consider extraction techniques, other than a carry chair. The independent expert set out that there was a failure either to use a system to allow the patient to be carried flat, or to have such a system available.

Sabrina subsequently suffered a catastrophic collapse whilst in the carry chair. She went into cardiac arrest and, despite rapid transport to hospital, arriving at 22.41, she was declared dead at 23.24.

I heard evidence from a Consultant Gynaecologist, based at the hospital at which Sabrina died. She stated that, had Sabrina arrived in A&E at a point prior to cardiac arrest, then, on the balance of probabilities, the ectopic pregnancy would have been diagnosed and she would rapidly have had life-saving surgery.

(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed.

(2) A related issue about which I am also concerned is that LAS set out that there are 400 vacant positions, without further detail as to what steps are being taken to address this shortfall;

(3) Several training issues were prominent at the inquest and evidence has been provided as to how some issues have been addressed. However, I am concerned that some training issues remain outstanding;
(a) I heard from the consultant Gynaecologist that all women of child-bearing age, with abdominal pain, should be considered to be pregnant, until proven otherwise through pregnancy testing. This contrasts with the training material provided by LAS and also with their stance on not (currently) testing for pregnancy on the scene;
(b) Given the issues raised by the independent expert regarding extraction techniques, I remain concerned that the crews had insufficient knowledge of alternatives steps, which could have been taken to remove Sabrina to the ambulance;
(c) Evidence has been provided that specific training ‘case studies’ will be or have been published on the issues of ectopic pregnancy and transient capacity. Given that issues arose during the inquest, as to whether such case studies appropriately covered the relevant points, I seek confirmation that these case studies have been published (through provision of copies), so that I can be reassured that these training issues have been addressed;

(4) The potential for systems improvements, such as automated recategorisation, clinical re-triaging and feedback to call-handlers regarding current time-frames were raised during the inquest. These are issues which, if not implemented could risk future deaths and I remain concerned that they have apparently not been implemented or considered by LAS;

(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view;

(6) Substantial concerns were raised in the inquest regarding LAS’ governance processes, specifically regarding its ability to undertake internal investigations. Attempts were made to address this but more recent evidence submitted demonstrates that significant shortfalls remain. It is clear that the Trust are taking further steps to address this; however, more detailed information as to time-frames and progress in this regard are required.