Shocking litany of errors by ambulance call handlers on day of newborn baby’s death

The parents of a newborn baby in Walthamstow who died aged just three days old called 111 three times before an ambulance was sent – and were given incorrect resuscitation advice, an inquest heard.

Jordynn Edwards-Jeffers died at Whipps Cross Hospital on February 10, 2019 after she stopped breathing at her home. A post-mortem was unable to determine the exact cause of her death.

Jordynn’s parents called 111 at 9.48am that morning because she was not feeding but, after a series of errors, an ambulance was not dispatched until 11.23am, during their third call.

An inquest held on February 15 at Walthamstow Coroner’s Court heard that, since her death, the London Ambulance Service has completely overhauled how 111 deals with newborns.

The London Ambulance Service’s deputy medical director David Macklin told the court all three calls made by Jordynn’s parents to 111 that morning were not handled correctly.

The first call handler marked Jordynn’s case “priority five” when it should have been “priority one”, meaning there was a six-hour deadline to call back rather than 15 minutes.

Dr Macklin explained Jordynn should automatically have been the highest priority because she was a newborn and that the call handler was aware of this but “made a mistake”.

Jordynn’s father Kevin called back at 10.33am when they had not heard anything and after she had become irritable.

The call handler in this instance failed to ask if her symptoms had changed, with Dr Macklin adding that: “As a consequence, they did not pass the case to a health advisor for a full assessment.

“They should have done and that, once again, was an opportunity, where we never know what the outcome of that assessment would have been.”

The final call was made at 11.16am and Dr Macklin said it was “handled very poorly”, with the staff member failing to ask questions as scripted and giving incorrect resuscitation advice.

Dr Macklin said: “They did not reach the recognition that the child was probably not breathing at that stage or was certainly so unwell as to make that an imminent danger.”

He noted that Jordynn’s dad was told to put her on her side when she appeared to start breathing again but should have been told to keep going with CPR until the ambulance arrived.

The court heard that, since her death, the LAS had carried out “a system-wide review” of its care for neonatal patients.

Parents of patients that are four weeks old or younger are now transferred to a GP immediately, with Dr Macklin noting the service had “increased the number of GPs specifically to be able to do that”.

111 call handlers were also given extra training, with Dr Macklin adding this had been “very well received” by staff, who it emerged “actually were not confident” beforehand.

In particular, staff were trained in giving CPR themselves, which he said “greatly assisted with their ability to understand the techniques they are describing and is now standard practice”.

All three members of staff that dealt with Jordynn’s case were “taken off call duties for a period of monitoring and supervision”.

Two of the staff members were eventually deemed ready to return to active duties, while the third is still absent on maternity leave.

Despite the mistakes made, Dr Macklin was not confident it would have been possible to save Jordynn if her case had been handled differently.

He said: “It’s always dangerous to assume what might have happened if something had been done differently. Unasked questions at an unknown time cannot produce definitive conclusions.

“I think Jordynn was very unwell even by the time of the first call, it does not sound as if she had fed since 6pm the night before, that’s a prolonged period of time for a newborn.”

East London coroner Nadia Persaud agreed that the evidence did not definitively prove that “earlier ambulance attendance would have prevented Jordynn’s death”.

She said: “What we cannot say, because we do not have a precise mechanism of death, is whether earlier medical attention would have changed the outcome.”

The inquest concluded that Jordynn died of natural causes.

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Victoria Munro

Local Democracy Reporter