A 29-year-old man died after failures to provide “accurate and relevant clinical information” delayed an air ambulance from giving him life-saving treatment.
Nadeem Ahmed lacerated his brachial artery when he put his hand through the glass pane of a door at his home in Hulse Avenue, Barking, on February 8 last year.
However, two calls made to London Ambulance Service were “incorrectly triaged”, delaying the arrival of paramedics by around two minutes and resulting in an air ambulance team not attending the scene.
Senior coroner Nadia Persaud has penned a Prevention of Future Deaths report following the conclusion of an inquest into Nadeem’s death, at Walthamstow Coroner’s Court on June 16.
The court heard how Nadeem died as a result of “traumatic exsanguination of is brachial artery”.
However, his death was contributed to by failures to provide accurate information to the Helicopter Emergency Medical Service (HEMS) team and by a failure to ensure the earliest possible activation of the HEMS clinicians through correct call triaging, the report says.
Having been delayed in attending the scene, paramedics arrived to find Nadeem had “clear signs of hypovolaemic shock” – the loss of a significant volume of blood.
Had relevant and accurate clinical information been provided to the HEMS dispatcher, an air ambulance team would have attended.
They would have administered sedation, inserted a central line and administered blood products.
The reports says these interventions “would on the balance of probabilities have prevented Mr Ahmed’s death”.
The correct triaging of the 999 calls would have provided an opportunity for earlier attendance, increasing the likelihood of Nadeem receiving life-saving treatment.
As a result of the delays, Nadeem did not receive any bloods prior to suffering cardiac arrest while en route to the Royal London Hospital.
He subsequently suffered multiple organ ischaemia and he passed away at the same hospital on February 13.
Ms Persaud highlighted areas of concern that need to be addressed in order to prevent further deaths in the future.