An ambulance call-handler has been found in breach of a patient’s right to a professional standard of service after a teenage girl died with an asthma attack following a delay in sending an ambulance.
In 2020, the teenager was in her bedroom when she sent two texts to her mother saying she needed her prednisone and that her nebuliser was not helping around 7.45pm.
The mother gave her daughter the medication before calling 111 at 7.57pm.
When asked by the call-handler if her daughter was breathing, the woman replied, “Yip, probably 25% maybe, yeah”.
The call-handler told the Health and Disability Commission (HDC) it was “difficult to understand the severity of the situation”, but did not clarify what she meant by 25% before selecting “yes” in the ProQA system — a software tool determining triage categorisation.
The mother was then asked if her daughter had any difficulty speaking between breaths, to which she turned and asked, “Can you talk in between your breaths?” The teenager replied, “No, no”. The call-taker interpreted the response to mean she was able to speak between breaths and selected “no” in the system. He later said he had recorded the answer incorrectly due to “human error”.
Towards the end of the call, he told the mother an ambulance had been arranged but to “call us back immediately for further instructions” if her condition worsened.
At 8.15pm, a second 111 call was made by the mother’s younger daughter as the teenager’s condition deteriorated, and her breaths were becoming shallow and short.
An ambulance was dispatched immediately, arriving at the family’s house at 8.25pm. It was followed by a second ambulance at 8.33pm. Fire and Emergency New Zealand services were also requested, arriving at 8.30pm.
However, by the time the emergency services arrived, the teen was positioned on the floor, unresponsive and not breathing. While resuscitation efforts were carried out by her family and ambulance personnel, she was declared dead at 9.38pm.
“I firmly believe that had they arrived promptly after the initial 111 call, [my daughter] would still be alive today, and that thought torments me,” the mother told the HDC.
Deputy Health and Disability Commissioner Vanessa Caldwell found the call-handler in breach of Right 4(2) of the Code of the Health and Disability Services Consumers’ Rights for failing to provide services complying with professional standards.
In her report released today, Caldwell said the call-handler “failed to obtain, clarify, understand, and record accurate information” about the teenager’s condition, and the “incorrect categorisation meant that the seriousness” of her condition “was not fully appreciated”.
Caldwell acknowledged the call-handler’s “cooperation and reflection” with the review, as well as the “high-pressure environment in which call handlers operate”.
“As with all emergency sector roles, these often involve rapid decision-making without the benefit of all the information. In this case, as [the call-handler] and the review have determined, it was human error that resulted in [the call-handler’s] failure to accurately interpret and record some of the information given by [the mother].
“As such, the standard of service that [the mother] and her family received fell short of the standard expected, and the breach decision reflects this.”
Caldwell recommended the ambulance service where the call-taker worked to have a conversation with the International Academies of Emergency Dispatch about ProQA breathing questions.
She also recommended the service use an anonymised version of the report to be used as a training session for call-handlers with a particular focus on managing calls where a patient was having an asthma attack.
Caldwell also recommended the call-handler — who has since left the ambulance service — should provide a written apology to the girl’s family.