Mum says 999 delays contributed to death of her son in Cwmbran

Mark Rawlings, 36, of Cwmbran, who had battled the debilitating effects of epilepsy for almost 18 months, died on June 10 this year.

He became trapped behind a bathroom door at a friend's home in the town, after collapsing during a seizure shortly after 7.40am.

The Welsh Ambulance Services NHS Trust (WAST) concluded, following a complaint investigation, that it breached its duty of care towards Mr Rawlings on two grounds.

The emergency call was categorised wrongly as 'amber 1' (high clinical priority response) instead of 'red' (immediately life threatening) - and it overlooked the availability of a Rapid Response Vehicle (RRV) which it estimates could have arrived five minutes earlier than the ambulance.

But despite the consequent delay, the trust concluded too, that "on the balance of probability the outcome for Mark would sadly have been no different."

Firefighters alerted by the ambulance crew cut open the door, and treatment began at 8.10am, 27 minutes after the 999 call. Despite this, and efforts on the way to and at the Royal Gwent Hospital, Mr Rawlings died.

The report reveals too, that police were called out at 7.48am as a result of the 999 call, but this request was cancelled three minutes later "when it was realised it was an internal door that was blocked."

"The (ambulance) trust does not routinely ask assistance from our emergency service colleagues in such circumstances, but awaits a dynamic risk assessment from the attending staff to determine what, if any, assistance is needed."

Mr Rawlings' mum Kay Westwood is shocked by the WAST report, and angered by its conclusion.

It concludes that Mark could have been reached 22 minutes after the 999 call, rather than the actual 27 minutes.

But Mrs Westwood, who lives near Swansea, believes the fire service should have been called out when the 999 call taker was told her son was trapped.

"That was made clear straightaway, but they waited until the ambulance had arrived. The crew called the fire brigade," said Mrs Westwood.

"The report says the ambulance arrived at 7.53am and the fire service was called at 7.59am. They got there in four minutes, but that was 16 minutes after the original 999 call.

"We are convinced the delay in reaching Mark was far more than five minutes. If the fire brigade had been sent immediately, he could have been reached 15 or 20 minutes earlier.

"We're not blaming any one person. It's more the way these situations are handled.

"From the start, they knew no-one could get into that room, but they waited to do a risk assessment. To us, that is precious minutes lost.

"We'll never know if this would have made a difference for Mark, but we feel a big opportunity was missed to save him. He was let down badly.

"If the protocol is not to send the fire brigade until the ambulance crew has done a risk assessment, and the police can't help in a situation like this, the protocol is surely wrong."

Mrs Westwood, who may take the matter to the Public Services Ombudsman for Wales, also said her son's friend is convinced an RRV arrived before the ambulance, though the complaints report states that only an ambulance attended.

She is also concerned it took more than three months before she received the complaint report - the standard is six weeks - and maintains she was not informed that more time was needed.

Claire Bevan, executive director of quality, safety and patient experience at WAST, reiterated the trust's "sincere condolences and deepest sympathies" to Mrs Westwood and her family for a "tragic loss".

"We fully appreciate what an upsetting time this must be for them," she said.

“We launched a thorough investigation to understand what happened. We have shared our findings with Mark’s family in full and are truly sorry where we did not meet our high standards."

Mrs Westwood has been invited to meet WAST representatives to discuss her concerns and that invitation "still very much stands", said Ms Bevan.