The National Ambulance Service (NAS) has pledged to restore publilc confidence in the system after a review found a 999 call taker did not follow protocol which resulted in an ambulance not being sent to help a dying toddler.
The tragedy has also prompted the introduction of a standby translation service to help staff at the country’s six command and control ambulance centres deal with callers who do not speak English.
The move was confirmed yesterday at the publication of a long-awaited review into the handling of a 999 call, which was triggered following the death of 2-year-old Vakaris Martinaitis, through injuries sustained in a fall from an upstairs window at his home in Midleton, Co Cork, last May.
NAS director Martin Dunne and medical director Dr Cathal O’Donnell accepted that the 999 call made seconds after the accident was not handled appropriately.
“Staff did not follow protocol. It resulted in an ambulance not being dispatched. We should have dispatched it,” said Dr O’Donnell.
“Staff acted in good faith but they did not follow procedures as they should have.
“I accept that public confidence has been shaken but we are working very hard to restore it.”
The Martinaitis family said they want lessons learned from the tragedy to ensure no other family has to suffer like they did.
Vakaris died on May 8 from injuries sustained two days earlier in a fall from a first-floor bedroom window at his family home in Midleton’s Castleredmond estate.
Neighbour Kevin Hennessy spoke during a 999 call to an ambulance controller, but language difficulties contributed to the call taker believing the child had suffered a simple fall, and was not as seriously injured as he was.
Based on this information, NAS staff decided to stand down an ambulance which was in Cork City at the time, 18 minutes away.
It meant Mr Hennessy had to drive the critically injured toddler first to SouthDoc, then under Garda escort to CUH.
The 54-page review compiled by an independent external team, chaired by Dr David McManus, the medical director of the Northern Ireland Ambulance Service, found that while ambulance control staff acted in good faith, they deviated from ambulance control procedure.
Dr McManus said while the handling of this call was “the exception rather than the rule”, its management resulted in failure to appropriately asses the child’s condition at the scene of an accident, and failure to provide post-dispatch advice to the 999 caller.
The review found no evidence that ambulance control staff at the Cork centre were overworked at the time, or that there was undue pressure on the system.
Dr O’Donnell said he has apologised to the Martinaitis family and insisted the NAS is fully committed to implementing the review’s 12 recommendations, a process being overseen by an implementation team.
The country’s six ambulance control centres are to be consolidated into one national centre — based at two sites, one in Tallaght and one in Ballyshannon, Co Donegal — by 2015.
The Cork control centre which was the focus of this investigation closed in May.
The report made 10 recommendations, with the National Ambulance Service (NAS) already implementing some of them.
* Recommendation: The NAS should amend the procedure for call taking, address verification, and dispatch to give higher priority to a 999 call when there is limited information or when the person(s) involved in the incident do not speak English.
* Progress: The NAS has engaged translation company Language Line to provide real-time interpreters for 999/112 call takers.
* The NAS must ensure that Advanced Quality Assurance (AQuA) — a special software tool which analyses how ambulance control operators ask questions, and how those questions are answered — is implemented in all NAS control centres.
* Progress: The software is now active in all control centres.
* The practice of combined roles for call takers and dispatchers should cease in all ambulance control centres, with clarity for each staff member on which role they are acting in to avoid any uncertainty or confusion.
* Progress: The practice of combined roles has ceased.
* All ambulance control rooms should have an assigned team leader or person in charge to supervise the call taking and dispatching process 24/7.
* Progress: NAS control centres now operate with control supervisors and a control manager on a 24/7 basis. A senior manager has also been appointed to support the day-to-day operations.
The NAS must ensure that robust arrangements are in place for the dissemination of policies, procedures and standards within the service and that a system is put in place to monitor ongoing compliance with HSE policies, procedures and standards.
The NAS must ensure the continued training and education needs of staff are met., and that staff have access to incident review documentation which gives feedback on incidents where the responses were inappropriate.
Implement good communication techniques through a training programme supported by a regular audit of call taker practice and feedback.
All NAS staff must adhere in full to all relevant NAS policies, procedures and guidelines. Monitoring of compliance must be incorporated into governance arrangements. The layout of the control room should not hinder verbal and non-verbal communication and should facilitate team working. NAS control room staff should not routinely refer 999/112 callers to a GP out-of-hours service without prior consultation with the GP service.
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