A THIRTY stone teacher died from a heart attack as firefighters discussed removing the window to get her out, an inquest heard.
Lytchett Minster School teacher Carol Beverley was suffering with a blood clot in her lung at her parents’ home at Stoborough, Wareham when she went into cardiac arrest on April 22 last year.
Paramedics gave evidence, at Tuesday’s inquest in Bournemouth, about Ms Beverley’s condition and that an extra-large stretcher - one of only two in Dorset - had to be organised.
But the stretcher was one of several delays that plagued the South Western Ambulance Service, it emerged, after a major system failure forced call-outs to be communicated by phone and radio.
As a result, the initial call regarding the physics teacher’s size and location from the on-site paramedic was missed and her colleagues were forced to go back to Dorchester to collect the specialised trolley.
They were also flagged down by police en route because of a road traffic accident.
Ms Beverley’s death sparked clinical reviews at both SWAS and Dorset County Hospital where the 43-year-old had been rushed to A&E the day before.
She was diagnosed with a urinary tract infection and sent home with antibiotics some hours later.
Dr Han Cao told the hearing she tried to keep Ms Beverley, who lived at Crossways, Dorchester, at the hospital overnight to assess the clot - which was then only suspected - but Carol became very anxious and refused to stay.
“She didn’t like the experience,” she said.
“I initially offered a hospital stay, then maybe a smaller ward, then the possibility of a smaller unit and when I said ‘what about a home visit?’ she said that was even worse.”
Dr Rob Torock, consultant in emergency medicine at Dorset who conducted the trust review, said it was clear there was “miscommunication and a misunderstanding between the attending doctor and senior doctor” - Dr Cao and Dr Vanessa Bell.
“In retrospect it appears treatment was missed for a pulmonary embolism,” he said. “It’s unclear whether her subsequent death could have been avoided. I’m very regretful; an opportunity was missed and it’s a shame. That is tragic but I don’t think it’s fair to criticise.
“I think there are going to remain some questions we continue to answer.”
The matter was referred to the Wessex Deanery but not onto the General Medical Council, Dr Torock added.
Carol’s sister Tessa Griffiths said after the inquest: “Carol was a beautiful, kind and loving person and we miss her terribly.
“When opportunities are missed by medical professionals, the consequences can be devastating. In these cases, it’s important that lessons are learned so this is not allowed to happen again.
“We are still coming to terms with losing Carol and ask to be allowed to grieve in private.”
Dorset coroner Sheriff Payne recorded a verdict of natural causes.
“An opportunity was missed to provide treatment that may have altered her death,” he said. “It appears that lessons have been learned and changes are being considered.”
South Western Ambulance Service buys extra-large stretchers
THE South Western Ambulance Service has been forced to invest in extra-large equipment across the trust and review its operations as a result of Ms Beverley’s death, Tuesday’s inquest heard.
Every ambulance will have a striker installed - a specialist trolley with high sides capable of transporting up to 50st in weight - over the next two years.
SWAS staff member Caroline Tonks, who conducted the clinical review, told the hearing: “We do have access to 17 stretchers across the trust placed strategically across the counties.
“Hopefully they will become available in every front-line ambulance.”
She also said that, on the day Carol died, engineers were replacing damaged hard drives lasting approximately three hours which caused significant communication problems for their western hub at Exeter where calls are received and the eastern hub at St Leonards where dispatchers are located.
“During the time the system was down business continuity plans were implemented,” she said.
“There were communication difficulties. There was no access to satellite navigation so everything was just being sent via radio.”
The inquest also heard there were no senior dispatchers on duty at St Leonards while the programme issues were ongoing.