Stoke & Staffordshire

Visit to Stoke-on-Trent GP 'may have prevented death'

Mark Hemmings
Image caption Mark Hemmings died from acute pancreatitis on 1 April 2013

A man with learning difficulties would probably have lived if an out-of-hours GP had seen him, a coroner said.

Mark Hemmings, 41, from Meir, Stoke-on-Trent, dialled 999 for an ambulance but was told he did not need one, an inquest heard.

Coroner Ian Smith said he died from natural causes, partly because he did not see the GP and partly because his non-attendance was not followed up.

West Midlands Ambulance Service was not to blame, Mr Smith said.

Dean Rowley, Mr Hemmings' cousin, said the family was "disgusted".

Mr Hemmings died from acute pancreatitis on 1 April 2013, after dialling 999 late on 29 March, the inquest at North Staffordshire Coroners Court heard.

Call handler, Heidi Nicholls, used a computer programme, which assessed he did not need an ambulance.

The vehicle was sent automatically while the computer was making the decision and was seconds away from Mr Hemmings' home when it was stood down.

Image caption Heidi Nicholls used a computer programme which said Mr Hemmings did not need an ambulance
Image caption Dr Sri Sukhavasi accepted Mr Hemmings was in severe pain, the inquest was told

Instead the matter was referred to GP Dr Sri Sukhavasi, who called him, accepted he was in severe pain and needed to be seen at an out-of-hours centre four miles away in Basford, Stoke-on-Trent.

But Mr Hemmings had no means of getting there and again requested an ambulance. He was found by his carer on Bank Holiday Monday extremely ill, had a cardiac arrest and was declared dead later that morning.

An ambulance service spokesman said "any early death is a tragedy" and offered condolences to the family.

He said: "We are pleased the coroner has accepted there is a need to triage (screen) 999 calls made to the ambulance service. He found Mr Hemmings' call was correctly triaged and there was no criticism of West Midlands Ambulance Service."

The out-of-hours GP service run by North Staffordshire Doctors Co-operative had lost its contract and was in the process of being wound up, the inquest heard.

Image caption Cousin Dean Rowley said a system which did not take into account vulnerable patients was dangerous

Mr Smith said it was hard to imagine somebody in pain not contacting anyone else, after those two calls, for two more days but "that would be to ignore the nature of the man".

Mr Rowley said a system which did not take into account vulnerable patients was dangerous.

The family has requested leave for a judicial review of West Midlands Ambulance Service's screening system.

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