Inquest into the death of Ffion Jones

Kate Lumbers was instructed on behalf of the family in this complex inquest, in which the coroner concluded that a 12-year-old girl would have survived if an ambulance had not taken an hour to reach her.

The S Wales Assistant coroner David Regan, reached a narrative conclusion that the failure of the Welsh Ambulance Trust 999 call handler to escalate a GP’s request for an  urgent ambulance to its clinical desk caused the death of Ffion Jones.

Ffion, who had undiagnosed Addison’s disease, and was suffering an Addisonian Crisis when she arrived at her GP surgery. The GP identified that Ffion was seriously unwell and called for an ambulance, requesting an 8-minute response at 14.24 GMT. Despite explaining that Ffion was seriously tachycardic, with elevated respiratory rate and unrecordable blood pressure, the GP’s request was not escalated, in breach of WASTs call-handling protocol.

Ffion went into cardiac arrest at 15.24 ,due to hypolvolaemic shock, just as the paramedics arrived. Despite resuscitation Ffion died in hospital. Paediatric intensive care evidence was that had Ffion received intravenous fluids and glucose prior to her arrest she would have survived.

The coroner made a prevention of future deaths report to Welsh Ambulance Service NHS Trust as he was not satisfied that sufficient measures had been taken to prevent a reoccurrence of death in similar circumstances in the future.

The case has been reported nationally and can be viewed here:


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