Toddler died after ‘human error’ by 999 control centre

A Mansfield toddler died accidentally from near drowning after having a seizure in the bath, an inquest has found.

Lacie-Mae Wilson died on April 1 after her mother pulled her out of a bath while she had a seizure, but a question mark hangs over whether an ambulance call handler could have prevented her death after failing to give proper CPR advice.

Assistant Coroner for Nottinghamshire, Jane Gillespie, turned a verdict of accidental death after hearing her mother acted swiftly to try and save the two-year-old after she inhaled an amount of water. Doctors were praised for doing everything in their power, although an East Midlands Ambulance Service (EMAS) control room operative was criticised for an ‘inappropriate’ handling of the situation, and subsequently resigned.

Forensic pathologist, Dr Roger Malcolmson concluded from his post-mortem exam on October 13 that Lacie-Mae suffered a “near-drowning in the context of a generalised tonic clonic seizure, complicated by pneumonia.”

“Her mum had been cleaning and was within view of the bath room.

Her mum saw Lacie-Mae splashing. She scooped Lacie-Mae out of the bath and began CPR because there was no pulse,” said the coroner, reading for the Pathologist’s report.

She had no heartbeat for almost half an hour, and after arriving at King’s Mill Hospital at 5.58pm was given treatment and regained a pulse at 6.05pm.

She was kept on a course of adrenaline and died at 8.17am the next morning.

But the inquest at Nottingham Council House heard on March 8 that the situation was a tragic case of ‘human error’ by one member of the team.

EMAS control room manager Alison Crowe said the call was a ‘challenging incident’, as Lacie-Mae’s mother asked for advice on CPR before giving her details for the operative to dispatch an ambulance. The experienced emergency response handler struggled to communicate with the family in the desperate situation and was said to be repeating down the phone, ‘hello, hello’, as if he could not hear them.

Ms Crowe said he failed to use his training in calming techniques to take control of the call or to give proper guidance on CPR.

“It’s not what we expect of our call handlers,” she told the inquest.

“He didn’t follow his training. If he had done that he would have been able to take control of the situation. We know that there were customer service issues.”

The call handler resigned after an EMAS investigation was launched as part of its regular audit system, used in all cases where under-18s are involved in 999 calls.

In mitigation of the circumstances the representative for the NHS trusts, Amanda Wright-Kluger, said: “Once that call starts that triggers the dispatch process to try and find that resource even if you’re a few minutes into a call that resource is already being found.

She added: “We are of the opinion from what was said, that the caller was not going to give CPR due to the panic at the scene.”

The family probed staff at King’s Mill Hospital over whether Lacie-Mae should have been diagnosed with epilepsy sooner and given preventative medication.

Grieving mum Torrin Williams said: “I need to know why it wasn’t investigated further. It will always haunt me that I’ll never know if more treatment could have saved her life.

“I’m not looking for blame to be placed on any particular individual. I want practices put in place to make sure this doesn’t happen again.”

But her doctor at King’s Mill hospital said even though she had been treated for seizures previously there was no diagnosis for epilepsy, and the coroner found it would have been ‘entirely inappropriate’ to treat her for the condition.

Paediatric consultant, Dr Simon Rhodes said: “It wouldn’t be standard practice to start medication with the information we had,” added the paediatrician.

“There isn’t anything I would have done differently.” Since the incident, EMAS has imposed new measures to prevent future errors, including reinforcing a ‘help card system’ where call handlers can raise alarm with other staff if they have a challenging call, (and others).

Dad Adam Wilson added that the family is considering legal action against both EMAS and the hospital.

He said: “They didn’t handle the call properly and we don’t know if those two minutes could have given Lacie-Mae a fighting chance.”

Coroner concludes accidental death in case of ‘one-off tragic human error’ In her conclusion to the inquest, assistant coroner Gillespie said that by the time she reached hospital she had had no cardiac rythm, for at least 30 minutes, and would have had irreversible brain damage from hypoxia – the sustained loss of oxygen to the brain.

She added: “Sadly there was nothing which could have been done to save Lacie-Mae at that point.”

In relation to the call itself, she said: “The request for CPR instructions was lost, after 4 minutes 13 seconds instructions for CPR were given to a male neighbour. However, the instructions were incomplete and wrong.”

“The opportunity for earlier confirmation of the name, address and situation and the opportunity to give earlier, clear and correct CPR guidance was missed.”

“I simply do not know if, on the balance of probabilities, the outcome would have been any different for Lacie-Mae if CPR guidance had been given by the EMD four and a half minutes earlier and it would be completely wrong of me to speculate.

“The inappropriate handling of the call on March 31 was a case of human error. It is devastating and of no comfort to Lacie-Mae’s parents, I know, but I do not consider that there is a widespread issue with call handling at EMAS. This was, in my view, a tragic, one-off event.”

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