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Paramedic 'failed' meningitis victim inquest hears | Paramedic 'failed' meningitis victim inquest hears |
(about 1 hour later) | |
A paramedic missed an opportunity to deliver vital care that could have saved a Bristol meningitis victim's life, a coroner has said. | |
Mthuthuzeli Mpongwana waited for almost six hours for an ambulance but was initially told by a paramedic he had "man flu". He died two days later. | Mthuthuzeli Mpongwana waited for almost six hours for an ambulance but was initially told by a paramedic he had "man flu". He died two days later. |
Senior coroner for Avon, Maria Voisin, ruled there were "failings" in his care and reached a narrative conclusion. | Senior coroner for Avon, Maria Voisin, ruled there were "failings" in his care and reached a narrative conclusion. |
The ambulance trust has apologised for the "unacceptable delays" in his case. | The ambulance trust has apologised for the "unacceptable delays" in his case. |
Ms Voisin said: "Mr Mpongwana died from natural causes contributed to by a failure to take appropriate action in the face of an obvious need. | Ms Voisin said: "Mr Mpongwana died from natural causes contributed to by a failure to take appropriate action in the face of an obvious need. |
"That failure was at 1:50am on January 6, when a P1 (high priority ambulance) back-up should have been requested and benzylpenicillin should have been administered. | "That failure was at 1:50am on January 6, when a P1 (high priority ambulance) back-up should have been requested and benzylpenicillin should have been administered. |
"The inappropriate care that was given resulted in a missed opportunity for medical treatment to be given." | "The inappropriate care that was given resulted in a missed opportunity for medical treatment to be given." |
Mr Mpongwana's wife, Lisa Armitage, called the 111 NHS non-emergency number at 22:30 GMT on 5 January, reporting her husband was suffering from a sore neck, struggled to look at light and had a bad headache. | Mr Mpongwana's wife, Lisa Armitage, called the 111 NHS non-emergency number at 22:30 GMT on 5 January, reporting her husband was suffering from a sore neck, struggled to look at light and had a bad headache. |
Symptoms dismissed | Symptoms dismissed |
She was advised to wait outside her home and that a rapid response vehicle with blue lights on would attend. She was also warned her husband could have meningitis. | She was advised to wait outside her home and that a rapid response vehicle with blue lights on would attend. She was also warned her husband could have meningitis. |
Avon Coroners Court heard that paramedic Dana Noriega failed to spot signs of both sepsis and meningitis and dismissed his symptoms as "man flu". | Avon Coroners Court heard that paramedic Dana Noriega failed to spot signs of both sepsis and meningitis and dismissed his symptoms as "man flu". |
The court also heard that Mr Mpongwana, told the paramedic he had HIV and had been treated for tuberculosis [TB]. | |
Mr Noriega failed to administer penicillin which should have been given as soon as possible, as he was worried it would react with the patient's other medication. | |
Points West's health correspondent, Matthew Hill: | Points West's health correspondent, Matthew Hill: |
This case highlights the extreme pressure that lone paramedics can face - in this case a paramedic who admitted feeling exhausted at the start of his shift having worked over the new year. | |
Mr Noriega was dealing not only with a suspected meningitis sufferer but also with a man who had just told him he had HIV as well as treatment for TB. | |
He thought Mr Mpongwana was improving and didn't give antibiotics immediately because he was concerned they might react badly with other medication he was on. | |
The paramedic also admitted he should have called for a 15-minute emergency response ambulance straight away but he knew all blue-light ambulances were tied up. | |
So he tried to circumvent system by calling for a 40 minute response ambulance, which from his experience could work out quicker, but nothing came. | |
Over the past 20 years there has been a trend to increasingly employ single-handed practitioners. | |
The idea is that you have more units out in the field to react when they are needed. | |
The downside is that they often cannot transport patients to hospital - which is why the trust is now trying to address that. | |
Other delays were made by downgrading the case and failing to call for a high-priority ambulance until 03:50, by which time Mr Mpongwana's condition had deteriorated. | |
He suffered a brain injury and died in hospital the following day. | He suffered a brain injury and died in hospital the following day. |
A spokesman for South Western Ambulance Trust said it was "very sorry for the unacceptable delays Mr Mpongwana suffered" and had explained its findings to his wife Lisa. | A spokesman for South Western Ambulance Trust said it was "very sorry for the unacceptable delays Mr Mpongwana suffered" and had explained its findings to his wife Lisa. |
He added that "a number of improvements have been identified, especially around requests for back-up from clinicians on scene with patients who need to be transported to hospital". | He added that "a number of improvements have been identified, especially around requests for back-up from clinicians on scene with patients who need to be transported to hospital". |
Mr Noriega's case has been referred to the Health Care Professions Council and he has since left the trust. | Mr Noriega's case has been referred to the Health Care Professions Council and he has since left the trust. |
The trust was told by the coroner that no further action was needed. | The trust was told by the coroner that no further action was needed. |