A grandmother died in agony after she was forced to wait four hours for an ambulance.
Isabel Carter, 74, died following a catalogue of failings by East of England Ambulance Service Trust (EEAST), an inquest heard yesterday.
The service admitted it had made mistakes in responding to a call from both Mrs Carter’s husband, David, and from her GP.
Isabel Carter, 74, pictured with husband David, died of bowel ischaemia - restricted blood flow to the bowel - after an ambulance took four hours to arrive
Mrs Carter, who had bowel ischaemia – inadequate blood supply to the bowel which causes it to become damaged – started to suffer from acute stomach pains at her home in Wymondham, near Norwich, on the morning of December 2, 2011.
Her husband called their GP and she was visited by a doctor who examined her and called the Norfolk and Norwich University Hospital.
The doctor informed the hospital that she needed to get a seriously ill pensioner to the to the surgical assessment ward within two hours.
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She then phoned her surgery and told them to call an ambulance.
However, two hours later an ambulance had still not arrived so Mr Carter called the surgery again and was told to dial 999.
At the same time, the surgery also called the ambulance service to inform them that the call needed to be upgraded to an emergency.
However, the call handler did not upgrade the call.
Mrs Carter died following a catalogue of failings by East of England Ambulance Service Trust (EEAST), her husband David and daughter Karen heard at an inquest yesterday
By the time an ambulance did arrive, four hours after it was initially requested, Mrs Carter had collapsed.
Paramedics managed to resuscitate her but she died within ten minutes of arriving at the Norfolk and Norwich University Hospital.
The inquest was told that survival rates from bowel ischaemia are low even with the right treatment.
Senior manager Adrian Maasz led an EEAST inquiry into what went so badly wrong.
TIMELINE OF MRS CARTER'S TREATMENT
1.13pm - The Norfolk and Norwich University Hospital is called by Dr Watts to tell them about Mrs Carter
1.15pm - Dr Watts’ GP surgery calls the ambulance service requesting help
3.15pm - Mr Carter calls the surgery to tell them no ambulance has arrived
3.43pm - The surgery calls the ambulance service saying the request is urgent and Mrs Carter needs help
4.15pm - Mr Carter calls the surgery saying his wife’s condition is worsening.
4.20pm - The surgery and Mr Carter call the ambulance trust and are told paramedics are on their way
4.25pm - Call from control centre to ambulance in Thetford telling them to go to Mrs Carter’s house
4.38pm - Ambulance leaves Thetford for her home in Wymondham
6.27pm - Mrs Carter arrives at the hospital
6.37pm - Resuscitation attempts stop
He said that demand on the service that afternoon had meant the trust could not get to Mrs Carter within two hours.
Mr Maasz said: ‘Undoubtedly there were failings within the control room at that time.’
He said lessons had been learned from Mrs Carter’s case and that it had put in new procedures to ‘significantly’ reduce the chances of similar mistakes.
Recording a narrative verdict, deputy coroner David Osborne said Mrs Carter died from bowel ischaemia.
The couple moved to Norfolk to be nearer their only child, Karen Holland, and her two children.
Mrs Holland said today: ‘Mother was just fantastic.
‘She would take pride in everything I did as her only child and all the things her two grandchildren have done.
‘She was the heart of our family and we just miss her so much.’
Mrs Carter’s son-in-law, Barry Holland, said: ‘We have lost a loving wife, mother and grandmother.
‘The ambulance service let us down on the day. It let Isabel down on the day she needed it most.’
The East of England Ambulance Service said: ‘Following this incident the Trust launched an investigation to identify the issues that led to the delay in the ambulance attending Mrs Carter.
‘This investigation identified that on December 2, 2011, a number of factors contributed to the delay in the ambulance attending some of which included increased 999 call volume, staffing levels in the control room, and incorrect upgrading of the call.
The ambulance trust has apologised to Mrs Carter's family - husband David (left), son-in-law Barry Holland (centre) and daughter Karen Holland (right)
‘As a result of the investigation the Trust has increased staffing levels in the Norwich control room, made investment in the addition of more clinical co-ordinators for 24/7 clinical cover in the control rooms, education and training for staff and ensuring more communication around the correct comfort call process is made.
John Martin, interim Director of Clinical Quality said: ‘We have apologised to Mrs Carter’s family and shared with them the findings of our investigation and the actions we have taken as a result of this incident.