Coroner concerns over Reading woman's death after 111 call
An ambulance service has changed its call procedures after the death of a woman in her 80s who called 111 and said she was unable to move from her chair.Sandra Millard, 81, from Southcote Lane, Reading, was suffering from sepsis, infected leg ulcers as well as heart and kidney disease in May 2024.Corner Robert Simpson said after her initial call a clinician tried to call her back four times, but Ms Millard's phone was engaged and no ambulance was sent.South Central Ambulance Service (SCAS) said it had changed its procedures so in the future all immobile patients would be asked the same questions.
Mrs Millard was found dead the day after she called 111 by a neighbour.In a prevention of future death report Mr Simpson said he had "matters of concern" and there was "a risk that future deaths could occur unless action is taken".He said when SCAS call takers use the NHS Pathways triage tool, which indicates that if a person is lying on the floor with no reported injuries, they are prompted to ask additional questions.These include whether someone else is with them and if they can provide the number of a next of kin, who may be able to attend the caller while they wait for an ambulance.However, the same procedure is not applied when someone reports they are stuck in situ, for example they are unable to move from their chair.Mr Simpson said: "My concern is that the additional risks of a long lie, for example rhabdomyolosis, may well apply when someone is unable to move from any position.""I am pleased that they have agreed to amend their procedures swiftly," he added.A spokesperson for the ambulance service said: "We would like to reiterate our sincere condolences to the family of Sandra Millard."South Central Ambulance Service is dedicated to ensuring that we provide a safe service to our patients."Following the inquest into the sad death of Mrs Millard, we have committed to amend our local standard operating procedures to address the concerns raised by HM Coroner. "This will ensure the same detailed questions asked of patients who are unable to get off the floor are asked if a patient is unable to move from any position."NHS England has been contacted for comment.
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