Elizabeth Anne Lester · Prevention of Future Deaths report

On 22nd December 2014 I commenced an investigation into the death of Elizabeth Anne Lester born 17th June 1945. The investigation concluded on the 14th May 2015 and the conclusion was one of Misadventure. The medical cause of death was 1a Pulmonary Embolus 1b Deep vein thrombosis 1c Immobility due to right total knee replacement for osteoarthritis

This lady underwent a total knee replacement at Tameside General Hospital on the 23rd November last. She needed to be readmitted thereafter as an emergency and because of the badly constructed algorithms used by the Ambulance Service, there was a significant delay in properly prioritising her transportation to hospital.

As per National practice, the North West Ambulance Service uses Advanced Medical Dispatch System to prioritise calls, based on the answers to scripted questions. During the first call the call-handler asked the relevant questions and followed the “breathing difficulties” card. This card does not include any question as to whether the patient is suffering any chest pains. The call was allocated a green response and the “high volume script” was also given. In fact the patient was short of breath AND did have chest pains, but this was never enquired about.
On the second call to the Ambulance service, this aspect was asked about and the call was escalated to a Red response.
It is my firm belief, having come across this same issue in a number of inquests, that there is an omission in the ‘card’ for ALL breathing difficulties and it MUST be amended to include a question about chest pain. Breathing difficulties are frequently as a result of compromised heart and/or lung function and this should be queried.
I am told that the local ambulance service cannot alter the wording used but that this must be done by the suppliers of the software.