Needham Market: Retired police officer died in hospital after waiting more than six hours for out of hours doctor

The Coroner for Greater Suffolk Peter Dean

The Coroner for Greater Suffolk Peter Dean - Credit: Archant

A FORMER Suffolk police officer suffering from pneumonia died following “significant delays” in responding by the out of hours doctors’ service, an inquest has heard.

However, it cannot be established whether the delay in treatment to Shirley Pooley, 51, contributed to her death, the hearing was told.

Shirley Pooley, of Alexander Drive, Needham Market, died from pneumonia and septic shock after her desperate family dialled 999, after waiting more than six hours for an out of hours GP to visit her.

The 51-year-old had been unwell over Christmas 2010 but by December 27 her husband Gary became so concerned that he called the out of hours service, operated by Harmoni.

During his first call at 2.34pm the call handler told Mr Pooley that his wife’s condition was considered urgent but a call back from a GP within 20 minutes was likely to take longer due to the team experiencing a very busy period.

In a statement read by Greater Suffolk Coroner Dr Peter Dean, Mr Pooley said: “We were getting really worried, she appeared to be struggling to breathe.”

A GP called back at 3.35pm – three times the target wait time for a urgent call – but downgraded the call from urgent to routine, telling Mr Pooley a doctor would be sent in two to four hours after offering an appointment at the out of hours base – then at Riverside – but Mr Pooley said his wife was too ill to be moved.

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But discrepancies were raised by Dr Dean between Mr Pooley’s account and that of the GP.

Mr Pooley said he told the GP his wife was “struggling to breathe” but in the notes from the call – which was not recorded as is standard practice – referred to “no difficulty breathing”.

Mr Pooley’s statement added: “We waited and waited as Shirley’s condition got worse and worse.”

He called the out of hours service back but the call was not escalated to urgent again and eventually at around 9pm Mr Pooley dialled 999, at which stage his wife’s lips had started to turn blue from lack of oxygen.

Mr Pooley’s said: “By this time we were desperate.”

After being taken to Ipswich Hospital, Mrs Pooley passed away in the early hours of December 28 while being treated in intensive care.

Consultant pathologist Dr Julian Orrell, who performed the post mortem, recorded the cause of death as lobial pneumonia, a bacterial infection.

He said: “Lobial pneumonia is a treatable infection. In general medical principles the earlier someone is treated the better their outcomes.”

Echoing that sentiment, Dr Nicholas Innes, a consultant respiratory physician at Ipswich Hospital added: “It is never possible to say 100% whether different action being taken would have led to a different outcome. The more one has underlying health issues the less you would expect to see a patient recover fully.”

The mum-of-two had underlying health problems, suffering from the condition lupus which affects the immune system. As a result of her lupus, Mrs Pooley also suffered severe lung obstructions, meaning she was predisposed to illnesses like pneumonia.

Reaching his conclusion Dr Dean said: “Undoubtedly there were failures to respond and undoubtedly there were serious delivery problems.

“It is clear we can’t know if the outcome could have been different, but had Mrs Pooley been in hospital for six hours earlier, even with the same tragic incident the family would have at least known all was done that could’ve been.

“It is also clear there has been significant learning of lessons and that maybe of some solace to the family after what must have been an awful set of circumstances.”

Dr Dean added: “The only verdict I can record is a narrative verdict that Mrs Pooley died from lobial pnuemonia attributed by existing systemic lupus.

“There were significant delays in providing medical assistance for a variety of reasons but whether these adversely affected the outcome could not be established on the evidence.”

Mr Pooley added: “We as a family are totally devastated at the loss of a wife and mother to two teenage children.

“Words can’t describe how we feel.”

Regional director for Harmoni in Suffolk, Yee Lee Wright told the inquest “lessons have been learnt” and changes have been implemented in the wake of the tragic death of Mrs Pooley.

Immediately after the incident, Ms Wright said the members of staff concerned received extra training “reinforcing policies and procedures” – for example if a relative called back that call should be noted and the case escalated if the patient had deteriorated.

Another immediate change was the introduction of a second co-ordinator to lead each shift, allowing one to focus on dispatching doctors in cars and the other to focus on triage and monitoring the triage queue to spot for serious cases.

A senior clinician was also introduced to monitor the calls queue. And the number of cars avaiable was increased from 10 to 13.

At the beginning of 2011 a recruitment drive was launched to help employ extra staff to cope with periods of high demand.

Ms Wright said the new NHS 111 line would ensure a case like Mrs Pooley’s was not repeated.

Under the new system all out of hours calls will be handled by 111 health advisors, who undergo four weeks training and exams, who recommend the best health service for each patient.

An automatic alert, tells call handlers if someone has already called within the last 48 hours.

Karen Smith, in charge of patient safety and clinical quality for the Ipswich and East Clinical Commissioning Group (CCG) and West Suffolk CCG, who took over from NHS Suffolk on April 1, said formal investigations were carried out and rigourous monitoring and scrutiny of Harmoni is ongoing.

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