Ambulance services have been urged to look at how suspected overdose and poisoning cases are prioritised after paramedics took 45 minutes to reach a woman with known mental health problems.
Helen Sheath, 33, had been discharged from a mental health unit in early July last year and was still waiting for an outpatient appointment with a psychological assessment and treatment service when she took a fatal dose of sodium nitrate on 20 August.
Her father called an ambulance at 6.20pm when she had locked herself in a bathroom and was threatening to take the sodium nitrate. But Bedfordshire and Luton senior coroner Emma Whitting said her father could not tell whether or not she had taken it, and that in view of her history of suicidal ideation, the call should have been treated as a category two – with an 18 minutes response target – rather than a category three incident.
The first ambulance which was sent to her was diverted on route and it was only after a second call to the East of England Ambulance Service at 6.48pm, that the call was upgraded to category two – when the call handler selected a different set of questions, after being told she had ingested the chemical. A rapid response vehicle arrived at 7.05pm and the mental health street triage team attended six minutes later. Shortly afterwards she became acutely unwell and was taken to Bedford Hospital, where she received treatment but died shortly afterwards.
In a prevention of future deaths report Ms Whitting said: “If the first call had been coded as a category two, it seems likely that the rapid response vehicle, mental health street triage team (and even possibly the double staffed ambulance) would have arrived on scene much earlier (potentially just before or just after Helen had ingested the sodium nitrate) which could potentially have altered the outcome.”
The case comes just months after two other ambulance trusts were criticised in cases involving suspected or threatened overdoses.
The prevention of future deaths report was sent to the Association of Ambulance Chief Executives and the emergency call prioritisation advisory group, which is run by NHS England. Neither would comment other than saying they would respond to the coroner.
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Source: HSJ, 15 June 2020