Nurse died following “number of errors” during 999 call after collapsing on night out

Nurse died following “number of errors” during 999 call after collapsing on night out

 

A popular dad died after collapsing on a night out following a “number of errors” during a 999 call – including the closest ambulances not being sent to the scene.

‘Gentle giant’ John Harmon, 34, died in Anfield, Liverpool, on August 18 last year.

Mr Harmon, who was a nurse at Aintree University Hospital and had a two-year-old son, “missed an opportunity to have life-saving care” from paramedics as a catalogue of errors contributed to his death, the inquest heard.

A coroner’s court heard how after a 999 call was made, the incident wasn’t logged correctly and an ambulance travelling to care for him did not have its blue lights on, the Liverpool Echo reports.

Tragically, there were ambulances closer to the area where Mr Harmon collapsed – but they were not sent.

Anita Bhardwaj, area coroner for Liverpool and the Wirral, said: “Soon after the collapse a 999 emergency services call was made, there was a missed opportunity to provide lifesaving assistance to John when the call was not correctly categorised as a category one and as a result the cause of death has been contributed to by neglect.”

North West Ambulance Service has apologised to Mr Harmon’s family and said ‘lessons have been learnt’.

John’s father, Patrick Harmon, said: “I’m hoping that it will be legally known that John was neglected.

“Hopefully this will never happen to another person. It’s just not good enough in many respects, I feel like it needs to be known.

“John didn’t just die in vain on a street in a corner.

“He was a nurse for 11 years, and a very successful nurse. He was looking at going forward in his life and going up the ladder.”

An inquest, held earlier this month, heard how Mr Harmon had been socialising with friends and had a few drinks in Liverpool city centre on the night he died.

As he and a friend were leaving G Bar, on Eberle Street, John suffered an ‘unexplained collapse’.

Ms Bhardwaj said: “He immediately wanted water and the way he collapsed did not appear to be because of him being drunk.”

A pathologist also said alcohol did not contribute to John’s collapse.

Ms Bhardwaj added that Mr Harmon appeared to recover ‘quite quickly’ and he and his friend then made their way into a taxi to go home.

While on his way home, the taxi pulled over so Mr Harmon could get some money out of a cash machine. He was able to walk to the cash point and back to the taxi in good condition.

But when the taxi arrived at the friend’s home to drop her off, Mr Harmon appeared to be “profusely sweating and had appeared to have wet himself”.

Mr Harmon said he then didn’t feel well and wanted to go home, so the taxi started travelling towards his home to get him back safely.

Dashcam footage from the taxi showed Mr Harmon behaving in a normal manner.

As the taxi arrived to Mr Harmon’s address, on Armley Road, a “loud bang was heard” as he got out of the vehicle.

Ms Bhardwaj said: “John was found collapsed on the floor. Within seconds, John became unconscious.”

The emergency services were contacted and a conversation proceeded to take place between the North West Ambulance Service call handler, the taxi driver, and Mr Harmon’s friend.

While on the phone, Mr Harmon could be heard snoring, before he then vomited and stopped breathing.

CPR was commenced at the scene by Mr Harmon’s friend, who was also a medical professional, and then he vomited again.

As paramedics arrived, attempts were made to clear Mr Harmon’s airway and he was taken to The Royal Liverpool University Hospital, where he sadly died.

Ms Bhardwaj said: “The post-mortem examination found John died of aspiration of gastric contents, but there were no pathological findings to explain why he collapsed in the first instance or a cause for the aspiration.

“During this incident, there were a number of errors identified.”

She said although the call handler dealt with the call in a
professional and calm manner, the call was very complex for a variety of reasons, including there being two people at the scene relaying information.

But the call handler was trained to recognise if the patient wasn’t breathing correctly and if any trigger words were used, such as “snoring”.

Ms Bhardwaj said the first error was made when the caller did not escalate the call to ‘category 1 emergency’ when she could hear Mr Harmon snoring.

The second error came when the call handler did not recognise Mr Harmon was displaying agonal breathing.

The third error was that the 999 call remained ‘uncategorised’ when paramedics were allocated to the incident.

The fourth error came when the ambulance on its way to the incident didn’t travel with blue lights or urgency, and no efforts were made to find out what the details of the incident were.

Patrick Harmon, who is also a nurse, said: “It was nine minutes before she [the call handler] realised John was in trouble and dying.

“It took them over 15 minutes to get to John and they stopped at two red lights. They actually stopped at two sets of lights on the way to an unconscious patient.

“He should have had CPR straight away because his breathing was poor, but that was advised nine minutes into the call.”

Ms Bhardwaj concluded: “This is a gross failure. Though it is impossible to know whether John would have had a different outcome if the call had been correctly categorised, what is clear is that as the cause of death is aspiration of gastric contents, the paramedics would have arrived at or around the time when John first vomited and so would have enabled them a better opportunity to clear John’s airways and therefore giving him a greater chance of survival.

“This was a missed opportunity to give John meaningful life saving care and treatment. And this failure has more than minimally, negligibly and trivially contributed to John’s death as it is directly linked to the cause of death.”

Paying tribute to his son, Patrick Harmon said: “He was in his prime, he was looking at specialising and he had everything going for him.

“He’d just got passed for a mortgage, but it’s all gone now. We’ll never see him as a dad, we’ll never see him old.

“I’ve got to die without him being by my side, that’s how sad I feel – the grief is horrible.

“He had a two-year-old son who’s now been left fatherless because of their actions.”

Director of operations for North West Ambulance Service, Ged Blezard, said: “Our sincerest condolences go out to the family of Mr Harmon and our thoughts are with them at this difficult time.

“We accept the coroner’s findings and conclusions.

“There was a delay in upgrading the emergency call which means there was a delay in getting an ambulance to Mr Harmon and we are deeply sorry that the care provided to Mr Harmon was below the standards we would expect.

“The trust strives to provide the very best care to all of our
patients but on this occasion, that was sadly not the case.

“Lessons have been learnt for the organisation as a result of a full internal review into this matter and changes have been made in our emergency operations centre to avoid this happening again in the future.”

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