Diabetic woman found dead at Staffordshire home 15 hours after calling 999

A diabetic woman, who was suffering from dangerously high blood sugar levels, was found dead by paramedics who arrived at her home 15 hours after she had called 999. 

Sandra Diane Finch, 44, who had Type One diabetes, had been taking antibiotics that doctors said may have resulted in her sugar levels rising.

Miss Finch, from Lichfield, called 999 and told operatives she was feeling 'sleepy'. She also said her glucose levels were high and she had been vomiting.

The call was listed under 'category three', meaning it was a medical emergency and an ambulance was required, with a target response time of an hour.However, the clinical validation team that had to carry out a review before the ambulance could be sent was 'under-staffed' and 'had no time limit attached for an assessment'. 

That meant no assessment was attempted until Miss Finch failed to answer a call back from the ambulance service at 7:22am the following day - 10 hours after she had dialled 999.By the time the ambulance arrived at her home on Curborough Road at 1:08pm on 5 December 2021, she had died from ketoacidosis - dangerous acidic deposits released when patients' sugar levels are excessively high.

Clinicians told coroner Emma Serrano that Miss Finch's call should have been a 'category two' case, in line with those who have suffered a stroke, heart attack, severe blood loss or trauma.

The target arrival time in such cases is 18 minutes.However, clinicians said they believed Miss Finch would not have died when she did if an ambulance had arrived within the accepted category three time limit.

Last month, Ms Serrano, area coroner for Stoke-on-Trent and North Staffordshire, recorded a narrative conclusion at Miss Finch's inquest, saying she died of 'ketoacidosis due to insulin deprivation contributed to by neglect'.And now she has issued a report to calling for action to be taken by ambulance service chiefs to ensure similar deaths do not happen in the future.Ms Serrano wrote she was concerned: "...that the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path."This led to a type-one diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly."(And) that the use of an assessment team, to assess a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays."

A West Midlands Ambulance Service spokesman said: “We would like to convey our deepest sympathies to the family of Miss Finch. The introduction of the Clinical Validation Team has led to significant patient benefits."Almost 200,000 callers have received the necessary care they required much more quickly than they would have done had we been sending an ambulance to every case."All category three and four incidents, except for a predefined list of exemptions now go directly to the clinical validation team. For those where no ambulance is initially sent, outcomes range from a higher ambulance response category, referrals into urgent and community services, and self-care advice."By appropriately reducing the requirements for emergency ambulances, those patients with the most acute needs get an ambulance more quickly, while those with less urgent needs get the advice or referral that they require more rapidly than would have been the case."The trust now aims to contact category three and four patients for a clinical assessment within 60 minutes. Patients are prioritised for call back in time order, within their incident category."