Man who died after arm was left '˜hanging off' in horror fall received '˜fatally flawed' 999 response
A man who died after suffering severe blood loss following an horrific fall at home which left his arm 'hanging off' might ave survived but for a 'fatally flawed' response from emergency services.
James Quinn, known to his family as Jimmy, suffered serious injuries to his right arm after falling into a glass cabinet at his Washington home.
But a 999 call by the stricken 61-year-old led to a catalogue of errors and a communication breakdown which meant he died from what a coroner described as “potentially survivable” injuries.
Now both Northumbria Police and North East Ambulance Services have promised to learn lessons from the tragic death.
An inquest into Mr Quinn’s death heard he suffered a fall at his home on July 1, 2016.
At 7.05pm, he made a 999 call and asked for an ambulance, telling the operator that his “arm was hanging off”.
But the operator failed to record information about the seriousness of Mr Quinn’s injuries - which should have triggered the immediate dispatch of an ambualnce to arrive at his home in eight minutes or less.
17 minutes later, when an ambulance had still not arrived, Mr Quinn called 999 again.
The call was this time graded correctly and Mr Quinn told the operator he was unable to make it to the door which was locked.
He said he kept passing out and that someone would have to break in.
The inquest, which took place at Gateshead and South Tyneside Coroners Court, heard that North East Ambulance Service (NEAS) contacted Northumbria Police and made clear what had happnened and that they would need assitance to gain entry into Mr Quinn’s home.
But the hearing was told that the message was misinterpreted and an officer made the decision to delay attendence under the mistaken belief that the ambulance crews would make further contact if police were required to attend.
An amulance arrived soon after and Mr Quinn’s partner and sister were contacted by a neighbour.
Paramedics did not force entry to the property themselves as the ambulance service does not have the same legal powers as the police and fire and rescue service to force entry to a property.
Ambulance staff had no training about forcible entry and did not carried specialised equipment.
The inquest heard evidence from Dr Peter Goode, consultant in accident and emergency medicine, who concluded Mr Quinn’s injuries would have been surivivable with prompt assessment and treatment up to 7.45pm that evening - more than 40 minutes after the fall.
But at that time police had still not been dispatched to allow paramedics to gain access.
Mr Quinn’s partner and sister arrived and tried to gain entry using a key but it snapped due to his own key being in the lock on the other side.
Police officers did not arrive until 7.56pm - 20 minutes after the incident was sent to the control room.
Emergency services gained entry just after 8pm but by this time Mr Quinn’s injuries had become fatal and he later died in hospital.
Coroner Terence Carney said: “The services that were in place may have worked on other occasions. But they were fatally flawed.
“I am told that the police and ambulance service have not been able to find any documentation about arrangements between them (governing forcible entry to property).
“The informality of the arrangement between police and ambulance service is astounding in the modern age.
“The fact that cooperation involved a decision not to train staff in forcible entry, and to discourage them from carrying out forcible entry, underlines an essential need to ensure that the system was robust, and that it was followed, to provide an obvious solution to an obvious need.”
The pathologist confirmed Mr Quinn’s caused of death was exsanguination, a severe loss of blood.
Mr Carney concluded the inquest with a narrative conclusion, saying: “Due to a failure to send an ambulance earlier and a failure by police to respond promptly to a request for attendance, there was a time critical delay in the delivery of essential medical care, and Mr Quinn died from otherwise potentially survivable injuries inadvertently sustained in a fall.”
In a statement from Mr Quinn’s family, they thanked the Barrister Paul Clark and Solicitor Gemma Vine for their support.
It said: “It is of huge relief that our concerns have now been recognised. Jimmy is missed deeply by all of his family and friends.”
His sister Joanne Quinn said: “We all miss him terribly. In the back of our minds we always knew he should still be here but to have it in black and white it breaks our hearts.
“He was such a lovely man, always smiling and wouldn’t hurt a fly.
“He loved Sunderland football club.
“I hope he hasn’t died in vain and the emergency services learn from this.”
Family solicitor Gemma Vine said: “This is a tragic case of an utterly preventable death which has occurred due to numerous mistakes and critical time delays by those emergency services that are supposed to be there to help us.
“Jimmy called 999 in his hour of need and was profoundly let down, resulting in his untimely death.
“We just hope that North East Ambulance Service and Northumbria Police take on board all of the lessons learned from Jimmy’s tragic death to prevent other unnecessary deaths occurring in the future.”
Northumbria Police Assistant Chief Constable Ged Noble said: “Our thoughts continue to be with the family and friends of James Quinn at this extremely difficult time.
“The inquest into Mr Quinn’s tragic death has clearly raised learning points for both Northumbria Police and North East Ambulance Service.
“I would like to give assurances that steps have already been taken to address the issues which led to the delay in treatment being administered. This includes new procedures with the relevant agencies around gaining access to properties when someone requires medical assistance.
“The force also referred a complaint about the incident to the Independent Office for Police Conduct (IOPC) and while its investigation concluded there was no case to answer for misconduct, failings were identified which we have addressed.”
Chief operating officer at NEAS, Paul Liversidge, said: “This was a tragic case and we send our condolences to Mr Quinn’s family.
“As a result of this case we carried out our own investigation of the circumstances involving Mr Quinn’s care and reported the incident to the wider NHS system, which oversees our performance and the quality of our care.
“We have implemented a number actions to address the issues highlighted by our investigation.
“We will continue to work with our emergency service colleagues to ensure that together we improve the standard of care provided to people who come into contact with us, regardless of which service reaches them first.
“As an ambulance service, we do not have the same legal powers as the police and fire and rescue service to force entry to a property and our employees neither have the training, nor the specialist equipment necessary available to them.
“We work closely with other emergency services to respond to patients where access is difficult. At the time of this incident, we had an arrangement with police services for them to attend to assist with forcible entry. This had been practice for a number of years and is a nationally recognised approach. More recently, further arrangements have been implemented to allow the fire and rescue service to also assist us in this regard.
“The Coroner recognised that other emergency services have greater skills, equipment and expertise in forcing entry. This enables our highly trained emergency care crews to enter premises safely, without risk of injury, so that they can immediately attend to those who need our help.”