A little Oldham boy fighting for life during an asthma attack died after a ‘tragic’ blunder by a 999 call handler led to an eleven minute delay in paramedics treating him.
Clayton Barker was struggling for breath but paid with his life when he was overheard telling his grandmother he was eight and not seven years old.
The call handler who had asked a scripted question ‘is he having any difficulty speaking through breaths?’ wrongly assumed Clayton could speak, and unwittingly coded his situation as less serious than it actually was.
It resulted in an ambulance being sent to a different house instead.
Paramedics eventually arrived 23 minutes after the 999 call and got Clayton to hospital 22 minutes later but he was pronounced dead on arrival. Tests showed he died of an acute asthmatic attack.
Inquiries discovered the unnamed call handler had made a ‘subconscious and isolated’ mistake while fielding up to 80 calls during a 12-hour shift.
An inquest was told gymnastics fan Clayton, from Oldham, Greater Manchester, was one of three brothers and described by his mother Gemma Barker, 31, as ‘mischievous and full of life and energy.’
He had been diagnosed with asthma when he was five and attacks could be triggered by exposure to cat and dog fur, hot summer weather and even snow.
The youngster was given a blue then purple inhaler which he used twice in the morning and twice in the evening.
But he was admitted to hospital several times – including an attack on his eighth birthday in January last year – which caused him to be kept in overnight.
He was admitted to A&E on March 10 but was discharged that night and went to school the following day.
Tragedy struck four days later when Clayton was offered a sleepover at the home of his grandmother Elaine Barker, 48, in Derker, Oldham.
That day he was seen to be a ‘bit wheezy’ but recovered after taking his inhaler and finished school at 3.15pm.
Gemma told the Heywood inquest: “He was okay when he returned. He was playing outside for about an hour. We then went to my mums because he was sleeping over that night.”
Clayton was dropped off for tea but at around 7.17pm Gemma got call from her mother.
She added: “She said Clayton was wheezing. I thought he was okay but I could hear him in the background. I told her to give him his inhaler.
”Whilst on the phone I could hear Clayton panicking. I could tell by the tone of his voice. I told her I would come back and that she should ring the ambulance”
While Elaine rang 999 Gemma phoned a taxi driver friend who lived nearby and he took her to the house.
When she arrived there was no ambulance and she assumed Clayton had already been taken to hospital.
But Gemma added: “I was just stepping out of the taxi when I saw Clayton running out of the house.
He was wheezing. He was then running around the garden, he was trying to get his breath back. He was leaning back. I had never seen him in such a state before.”
She said she considered taking her son to hospital in the taxi and said: “He collapsed as I was holding him. I was lifting him up off the ground, carrying him like a baby to get him to the taxi. His eyes just shut and he stopped breathing and he was limp.”
Elaine made a second 999 call at 7.31pm to ask the whereabouts of the ambulance while Clayton was placed in the taxi where the friend attempted CPR.
An ambulance eventually arrived at 7.40pm and left the house at 7.56pm before arriving at Royal Oldham Hospital at 8.02pm.
Angela Lee, the assistant service manager at the Emergency Centre of North West Ambulance Service, said inquiries showed the call handler had made an error whilst asking a series of scripted questions to Elaine during the 999 call.
Mrs Lee said: ”We went through the call. She said that when she was asking the questions ‘how old is the child?’ The gran said to the child and the child replied ‘I am 8 not 7’ when she said ‘7’.
”The caller heard him in the background. The next question was ‘is he having any difficulty speaking through breaths?’
”The caller said she heard the child speak in the background and in her subconsciousness clicked ‘no’ when it was ‘yes’. We have talked about valuing the integrity of the caller. It is a human error.”
But due to the mistake error Clayton was perceived as less urgent and his case was coded as ‘green’ instead of the more serious ‘red.’
Mrs Lee said: “The calls for immediately life threatening conditions are categorised as Red 1 and Red 2, which means we respond in 8 minutes.
”We also have four green responses. Green 1 and 2 are to be responded to in 20 minutes and green 3 as telephone triage within 60 minutes. With green 4 codes we respond within 1 to 4 hours.
“The first call received by the emergency operator was at 19.17 on 14th March. It was given a green 1 response. The call for Clayton was green and should have been code red.”
The inquest heard an ambulance could have been dispatched to the Barker household at 7.21pm, which was just six miles away and could have reached the property by 7.27pm.
But due to the coding of Clayton’s case the vehicle was sent to the home of a two year old toddler instead.
The ambulance which was sent to the Barker house was dispatched at 7.29pm from Ashton-under-Lyne which was 11 miles away and 11 minutes to arrive.
Mrs Lee said: “That evening was extremely busy. There was a huge influx of emergency calls after 18.05pm. 51 calls were sending.
“At 19.00 pm there were 58 incidents still waiting. We had to instigate calling back emergency calls. It shows the significant demand that evening.
“The call taker has had a period of reflective action which has meant she has reflected on the on the call itself.
“She listened to it to see what went wrong. We have also issued a bulletin to staff of NWAS about the importance of recording information accurately given by the caller.”
Representing NWAS, lawyer Mr James Down: “It is an isolated error by a person. It is human error, a tragic mistake.”
The inquest was adjourned until June for an expert witness to be called to establish whether the time difference could have meant Clayton’s life being saved.
Coroner Simon Nelson said: “Mrs Barker you have shown great dignity by your presence here today. You will remember with great affection all the great traits Clayton clearly had in his character.
“I also commend Mrs Lee for coming forward and giving the evidence as she has done so.”
Story via Cavendish Press.
Image courtesy of chapstickaddict, with thanks.