An ambulance call handler's been found to have made a mistake in recording the seriousness of a teenage girl's asthma, before she died a short time later.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell released a report into the death on Monday, which found the call handler breached the Code of Health and Disability Services Consumers’ Rights.
It comes after the teenager's mum called to say the girl was having an asthma attack and had trouble breathing in 2020.
The girl and her whānau had been managing her asthma for many years.
The teen had texted her mum about 7.45pm in the evening, saying she needed prednisone and that her nebuliser was not helping her.
Her mum, identified only as Ms B in the report, told the Health and Disability Commission (HDC): "Immediately I knew things were very bad as she wasn't showing any signs of concern earlier and the [nebuliser] almost always helped."
Ms B said that she gave her daughter prednisone and then called 111 at 7:57pm.
That initial call was taken by a man, referred to only as Mr C. He was a member of the International Academies of Emergency Dispatch and had the designation of EMD L2, which "indicates that the call taker is experienced (more than 1 year), has proven compliance levels when handling calls, and demonstrates a high level of expertise", the report noted.
However, the report states that Mr C incorrectly interpreted and entered critical details about the teen's breathing into the software that determines triage categorisation. This meant the seriousness of her condition was not fully appreciated and affected the subsequent dispatch of an ambulance to her location.
Just under 20 minutes later, when the teenager's condition had deteriorated, the family made a second call to 111 and an ambulance was dispatched immediately.
However, by the time they arrived, the teenager was unresponsive, not breathing and declared dead shortly afterwards.
A transcript of the initial call was provided to the HDC.
In the conversation, Mr C asked Ms B whether the teen was breathing, to which Ms B responded: "Yip, probably 25 percent maybe, yeah."
Mr C did not clarify what Ms B meant by 25 per cent. The options available in the communications centre's software tool, called ProQA, included 'yes', 'no', 'unknown', 'uncertain', and 'ineffective breathing'.
Mr C told HDC that he considered that the options of 'unknown' and 'no' were inappropriate options, and that the option of 'ineffective breathing' was difficult to assess. ProQA categorises 'ineffective breathing' as meaning that the patient is 'barely breathing', 'turning blue', or other 'reasonable equivalents'.
Mr C added that being given a numerical value to describe the girl's breathing "was hard for [him] to understand the severity of the situation".
So, Mr C selected the answer as to whether she was breathing as 'yes'.
The girl's mum, Ms B, told the HDC: "I responded that [my daughter] was only breathing at 25 percent, and to hear that this did not alarm [Mr C] is devastating to me as a mother. This figure should have set off immediate alarm bells for anyone involved, whether they were trained or not. The failure to recognise the severity of [my daugher's] condition and act swiftly is something I cannot comprehend."
On reflection, Mr C accepted that with the rarity of the phrase and the amount of thought required to interpret it "should have sparked further clarification".
"Call takers are trained to be proficient in the use of the ProQA triage system, rather than in the call handling for specific conditions," he said.
Throughout the recorded conversation, Mr C did ask questions about the girl's condition.
At one point he asked if the girl was having difficulty speaking between breaths, to which her mum turned and asked the girl if she could talk between breaths then responded "no, no".
Mr C admitted he made a "human error" in misinterpreting that the teenager could speak between breaths and categorised it as 'no' difficulty speaking between breaths in the ProQA system.
He took the 'no' response as an 'absolute' but did not note the fact that the question had been rephrased in a manner that led to a reversal of yes/no meanings in Ms B's response.
He told HDC that during training about how and when to clarify a response, call handlers were taught that "no is a clear no" and "yes is a clear yes", adding that clarifying these answers "is considered an over clarification causing delays and potential stress to the caller/patient".
Ms B said his excuse only caused more anguish.
"When [my daughter's] ability to speak was questioned, I vividly remember the desperation in my voice as I asked her amidst her breaths. It's excruciating to recall hearing her struggle and knowing she couldn't respond, I replied to [Mr C] "no, no". The fact that [Mr C] recorded her ability to speak incorrectly due to his own 'human error' only adds to the anguish," she told the HDC.
Dr Caldwell found the call handler did not provide services of an appropriate professional standard.
"Although the call-handler asked the correct questions, according to the software, he failed to correctly record and classify two questions regarding the teen's breathing and failed to clarify the answers with the teen's mother," she said.
Dr Caldwell also made an adverse comment about one of the ambulance dispatchers from the second ambulance service involved in this case, whose "error in judgement" resulted in the nearest ambulance not being dispatched immediately.
She also raised issue with the ambulance staffing levels and called for them to ensure that cover was adequate to maintain effective communication and not negatively impact dispatching decisions when staff were handing over for meal breaks.
Dr Caldwell considered that the systems and protocols used by the ambulance service are a reasonable equivalent of "national standards" for call-handlers.
However, since the events, the ambulance services and staff involved have made several changes including to arrange a face-to-face meeting with the girl's whānau and advocacy support to "enable the findings from the investigation to be conveyed in person".
Changes have also been made to ensure communication about risks to dispatch delays associated with dispatcher change, including meal breaks.
At a personal level, Mr C said he had extensively revised the handling of all calls involving patients with asthma, including understanding where he went wrong on this case.
Dr Caldwell also recommended Mr C makes a written apology to the girl's family within three weeks of her report.
