The family of a woman who died from sepsis after being kept in an ambulance in a hospital car park for more than two hours has said she was the victim of a “complete breakdown” in care.
Samantha Brousas, 49, died 48 hours after being admitted to an emergency department in north Wales that was described as severely overcrowded at the time.
Her inquest at north Wales coroner’s court was told that health professionals realised she had sepsis and needed antibiotics quickly but she remained in the ambulance.
The coroner, Joanne Lees, giving a narrative verdict, concluded that the delay in treating Brousas inside the hospital did not cause her death, but she said paramedics did not follow guidelines in failing to issue a “pre-alert” to accident and emergency staff.
Brousas, from Gresford, Wrexham, had been feeling unwell for more than a month when she attended her GP surgery in February last year and was told she had a viral infection.
Feeling worse the next day, her daughter called the NHS 111 service, which arranged for an ambulance, but on arriving at the hospital its crew were told there were no beds available, and the paramedics were unable to administer antibiotics in the ambulance. After eventually being admitted, Brousas died from sepsis two days later, on 23 February.
Following the coroner’s verdict, Brousas’s partner, Simon Goacher, and daughter, Sophie Brousas, said in a statement: “It is incredibly difficult for us to hear the complete chaos that Sam was faced with when trying to battle this life-threatening illness. We have heard details throughout the inquest of a complete breakdown in the care that Sam should have received.
“It is devastating to know that all those healthcare professionals who came into contact with Sam on 21 February recognised she had sepsis and knew only too well that she required intravenous antibiotics within at most one hour. Despite that recognition, Sam remained on an ambulance in the hospital car park for more than two hours without such treatment.”
Stephen Jones, a clinical negligence solicitor at Leigh Day, who represented the family, said: “We heard that the hospital was operating under extreme pressure, that the emergency department was severely overcrowded and that staff would have been unable to perform even routine observations reliably.”
Dr Brendan Lloyd, the deputy chief executive of the Welsh ambulance service, said steps had been taken to improve patient safety. He said: “There are clearly lessons to be learned from this case.”
A spokesman for Betsi Cadwaladr University Health Board, which runs the hospital, said: “We know that lessons must be learned.”
This week a woman in south Wales died after falling outside her home and waiting for several hours on a cold pavement for an ambulance.