A schoolgirl who died after waiting an hour for ambulance might have survived if her 999 call had been treated more urgently, an inquest has heard.
Ffion Jones, from Rumney, collapsed while at her local doctor's surgery after she had vomiting for 48 hours.
She had gone to see her GP surgery afternoon with her mother and was found to have an elevated heart rate, fast breathing and her blood pressure was so low it was unreadable.
Pontypridd Coroner’s Court heard that Ffion's doctor requested an eight minute ambulance to arrive given how unwell the youngster was.
However by the time paramedics arrived the 12-year-old had already gone into cardiac arrest. She later died in hospital.
Ffion's devastated parents, who are adamant lessons must be learned from the tragedy, are now considering seeking damages.
In an emotional statement, an stood alongside Ffion's mother Stephanie, dad Anthony said: "We remain devastated by the events...when we lost our precious daughter.
“Ffion was a generous, funny, bubbly little girl and was a pillar of our family. We miss her so much and struggle to cope with her loss."
Ffion was taken to her local GP surgery by her mother after complaining of tiredness over a weekend that led to severe vomiting on December 7, 2016.
Unbeknown to her family and her GP at the time, Ffion had Addison’s disease, a rare but treatable disorder of the adrenal glands.
Doctor Nicola Leeson, of Rumney Surgery, examined Ffion at about 2pm on Wednesday December 7, 2016, and called for an emergency ambulance. She told the court she had tried to request an eight-minute ambulance, but was informed that one couldn’t be provided.
Dr Leeson said she made her first call to 999 at 2.27pm. A first responder didn’t arrive until 3.21pm, by which time Ffion has gone into cardiac arrest. An ambulance arrived at 3.30pm.
She was declared dead at 1.31pm on December 8, 2016, at the University Hospital of Wales, Cardiff.
Doctors at the University Hospital of Wales, Cardiff, quickly established Ffion was suffering from hypovolemia and shock related to undiagnosed Addison’s disease.
Giving evidence at he inquest, interim area manager for emergency medical services at the Welsh Ambulance Service Trust Kate Blackmore told the court that the ambulance request was given an Amber Two priority rating.
As the GP disagreed with priority rating, she said it should have been referred to the clinical support desk who could have raised it to Amber One or Red - the most urgent.
“An audit was undertaken for the 999 call in question,” Ms Blackmore said. “It identified that although the categorisation was deemed appropriate based on the questions and answers, they felt the customer service provided to the GP was inappropriate.
“They have given incorrect advice when the GP attempted to escalate the priority response and they didn’t show empathy towards the GP who was demonstrating anguish at the emergency situation.”
She added: “The doctor had advised that she wanted to escalate the call. The call handler advised that that couldn’t be done.
“However, guidance had been issued that advised that in circumstances where the GP didn’t agree with the prioritisation of the incident, that it should be escalated to a clinical support desk clinician.”
Ms Blackmore said that an ambulance could have been made available at 2.45pm if the incident had been upgraded to Amber One before that time.
Susan Tuckett is the national clinical operations manager for the Welsh Ambulance Service Trust’s clinical contact centres. She told the court that she has experience working on the clinical support desk.
She said she believed that if Dr Leeson had managed to speak with a clinician on the support desk, the incident would have been escalated to Amber One.
“I think if this was me, red calls are for immediately life threatening incidents and I think it’s hard to say without knowing the answer to questions [that the GP would have given],” Ms Tuckett said.
“I would have thought this was an Amber One.”
Coroner David Regan said Ffion’s cause of death as hypoxic brain injury, out of hospital cardiac arrest and Addisonian crisis.
He added that the delay to escalate Ffion’s case by the call handler was “causative” of her death, and if it had been escalated “it is likely she would have survived” - and recorded a narrative conclusion.
Speaking after the hearing, Mr and Mrs Jones later thanked HM Coroner Mr Regan for his "thorough investigation of Ffion’s death".
In a statement they added: "We entirely accept the conclusions of the Coroner. Our family have the utmost respect for the front line staff of the Welsh Ambulance Trust and nurses and doctors at UHW.
“We hope that important lessons have been learned and that no family has to suffer as a result of system failures.”
The family’s solicitor Spencer Collier said: “We will now review the findings and decide upon our next steps, but it is likely that proceedings for damages will now be issued.”