A mother died from sepsis after a “breakdown in care” which saw her kept inside an ambulance in a hospital car park for nearly three hours, her family have said.
Samantha Brousas, 49, died from the condition 48 hours after being admitted to an emergency department in North Wales which was described as being severely overcrowded at the time.
On Friday, a coroner issued a prevention of future deaths report to the Welsh Ambulance Service, after paramedics failed to give a “pre-alert” to A&E staff at Wrexham Maelor Hospital that Ms Brousas was critically ill.
Coroner Joanne Lees gave a narrative verdict at North Wales Coroner’s Court, saying the delay in treating Ms Brousas inside the hospital did not cause her death, but paramedics had not followed guidelines in failing to issue the alert.
Ms Brousas, from Gresford, Wrexham, had been feeling unwell for over a month when she attended her GP surgery on February 19 and 20 last year and was told she had a viral infection.
Feeling worse the next day, her daughter called NHS 111 who arranged for an ambulance, but upon arriving at the hospital its crew were told there were no beds available, and paramedics were unable to administer antibiotics in the ambulance.
After eventually being admitted she died from sepsis two days later on February 23.
Following the coroner’s verdict, Ms Brousas’s partner Simon Goacher and daughter Sophie Brousas said in a statement: “We have heard details throughout the inquest of a complete breakdown in the care that Sam should have received.
“We all put our trust in the healthcare professionals to provide Sam with the best treatment and we feel that she was let down in the worst possible way.
“Nothing will bring our beloved Sam back but we urge all those that were involved in her care to learn lessons from what happened to her and work together to make sure that significant changes are made quickly.
“It is disgraceful that this could have happened and we want to make sure it does not happen to anyone else.”
Stephen Jones, clinical negligence solicitor at law firm Leigh Day, who represented the family, said: “The absolute tragedy of this case is that all those healthcare professionals who came into contact with Sam on February 21 recognised at the time that she had sepsis and understood that sepsis is a potentially fatal, time-critical condition.”
Dr Brendan Lloyd, deputy chief executive at the Welsh Ambulance Service, said it accepts the coroner’s conclusion and steps have been taken to improve patient safety.
He said: “There are clearly lessons to be learned from this case for both us and our colleagues at Betsi Cadwaladr University Health Board, which is why we have been working with them in earnest to reduce the risk of this happening again in future.”
A spokesman for Betsi Cadwaladr University Health Board said it also accepts the coroner’s verdict, adding: “We know that lessons must be learned.”