A little Oldham boy who died after an asthma attack could have been saved were it not for a blunder by a 999 call handler which led to an 11-minute delay in paramedics treating him, an inquest heard today.
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.
Today at an inquest in Heywood, a coroner recorded a narrative verdict saying Clayton would have had better chance of survival if the correct response to the 999 call had been deployed.
Coroner Simon Nelson said: “Had the correct response been generated then an ambulance would have arrived before rather than after Clayton collapsed, in which case, on the balance of probabilities his chances of survival would have been enhanced.”
He told the boy’s mother Gemma Barker, 32: “Your comment was that ‘the public message needs to go out concerning how life-threatening asthma can be. When you gave your evidence you struck me very much as a mother who genuinely cared about the welfare of her children.
“We know Clayton collapsed and when he collapsed and how absolutely awful it must have been for him and for the family to see in the moments before his collapse. All of this emphasises the absolute need for urgency when responding to infants and young children with asthma.
“The cases I have had to deal with over the years that are broadly similar are few in number. That perhaps accentuates the tragedy of Clayton’s circumstances. I am sure that the qualities that you refer to, that he was full of energy, that he was mischievous, will remain with you.
“As difficult as it has been I do hope you have gleaned as much as you could have gleaned from this inquiry. I extend my condolences to you and all those affected by Clayton’s sudden death.”
An inquest heard gymnastics fan Clayton, from Oldham, Greater Manchester was one of three brothers and described by his mother Gemma 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 said: “He was okay when he returned. He was playing outside for about an hour. We then went to my mum’s because he was sleeping over that night.”
Clayton was dropped off for tea but, at around, 7.17pm Gemma got a 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 – assistant service manager at the Emergency Centre of North West Ambulance Service (NWAS) – said inquiries showed the call handler had made an error while 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 sub consciousness 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’, which means a response time of eight minutes as opposed to 20.
The inquest heard an ambulance could have been dispatched to the Barker household at 7.21pm and, as it was just six miles away, it 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 the 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 took 11 minutes to arrive.
Mrs Lee said: “That evening was extremely busy. There was a huge influx of emergency calls after 6.05pm. 51 calls were sending. At 7.00pm 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 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.”
Dr Simon Nedel, a consultant paediatrician at London’s St Mary’s Hospital, compiled a report about the tragedy and said: “The main question I have been asked is if the ambulance arrived before his collapse, would his death have been avoided?
“The timeline suggests the ambulance arrived around 7.27pm and he collapsed at 7.32pm. There is little doubt that the presence of the ambulance prior to Clayton’s collapse is likely to have led to an improvement in Clayton’s chances of survival.”
After the case, the Barker family’s lawyer Zak Golombeck from Slater and Gordon said: “The evidence was unambiguous – had the initial 999 call been categorised correctly and attended Clayton in a timely manner, Clayton’s chanced of survival would have been enhanced.
“Gemma’s loss is not something words can describe. Clayton was a happy and lively young boy and deeply missed by his family, especially his two brothers. I will now be advising Gemma in relation to legal action against the ambulance service.”
Story via Cavendish Press
Image courtesy of net_efekt with thanks