1. It appears that great reliance was placed on the fact that was not in pain and had normal observations. Little consideration appears to have been given to the ‘second patient’ (Mia), whose condition could not be monitored by paramedics. We heard evidence that in fact not all placental abruptions cause the mother significant pain, or concerning observations, but for the baby, it can be akin to a cardiac arrest. This factor appears to have been overlooked in the trust’s subsequent investigation report, which refers several times to how reassuring clinical condition was, and was repeated in evidence by the paramedic witnesses. This is a clear training issue, and may well apply nationally.
2. No ‘open mic’ report was put out to see if other crews could make themselves available to attend this emergency.
3. Dispatchers appear to have allowed a situation to arise whereby the only 2 DCAs not attending other jobs were both on compulsory meal breaks and therefore unavailable at the same time. Whilst meal breaks are vital for staff, planning the timing of these, by ambulance control, is critical for patient safety. Meal break management is already under review by EMAS.
4. It was suggested that obstetric emergencies such as placental abruption could
5. It is clear that resources played a part in these tragic events. No DCA was available to attend this emergency until 30 minutes after the call, and it took a further 12 minutes for a DCA to arrive after that. The time between the 999 call and being handed over to maternity staff was an hour and 15 minutes. It was clear from the outset that would require urgent transfer to hospital – a mere 4 miles from her home address – but no resource was available. The evidence of those ‘on the ground’ clearly showed that this is far from an isolated incident, and I remain concerned that there is a risk of future deaths if this is not addressed.