Mistake meant time lost in fight to save Sprowston baby

Published:
6:00 AM July 29, 2022



Precious moments in a fight to save the life of a 14-month-old baby were lost because a 999 call was wrongly downgraded, an inquest has heard.

On August 17 last year, tiny Brooke Revell, from Sprowston, died in the Norfolk and Norwich University Hospital after going into cardiac arrest.

Mum Jade Bird immediately raised the alarm after finding her daughter “floppy” when collecting her and twin sister Savannah from their morning nap.


A mistake by an ambulance service call handler was discussed at an inquest into the death of Brooke Revell
– Credit: Archant © 2013

She frantically performed chest compressions and emergency breaths to Brooke as she phoned for an ambulance.

The call was originally classified as a category one call – the most severe – but during the nine-minute telephone conversation it was mistakenly downgraded to a category two.

It led to the ambulance, which was just moments from the family’s door, being diverted to another category call in North Walsham.

By the time the call was changed back to a category one and the ambulance rerouted again, almost two minutes were lost.

The mistake came after call handler Simon Nally failed to acknowledge that Miss Bird was performing CPR – and continued following the ambulance trust’s triage script.

The inquest heard that the East of England Ambulance Trust (EEAST) has certain trigger phrases and scenarios which speed up emergency calls – with one of these being when a caller is performing CPR.

When this happens, call handlers are immediately given emergency instructions to give to the caller.

But despite Miss Bird telling Mr Nally she was doing, he did not recognize it as CPR and consequently, these instructions came much later in the conversation.

Speaking after the inquest, Miss Bird said: “I did not feel like the call was particularly helpful and I never really felt as though the handler was in control of the situation.

“It feels as though if that could happen to me, it could happen again.”

Norfolk Coroner's Court, at County Hall in Norwich.

Norfolk Coroner’s Court, at County Hall in Norwich.
– Credits: Stuart Anderson

The inquest heard how Mr Nally had been through a “reflective” training process since the incident.

Area coroner Yvonne Blake questions how Mr Nally had not recognized that what Miss Bird was doing to her daughter was CPR.

He said: “I feel I am now more acutely aware if people have decided to start CPR. If I was presented with the same situation now I would do differently.

“I can say without any doubt that this call has stayed with me and shaped how I apply my learning and development in the control room.”

The court was told Mr Nally had started working in the control room as an agency worker in February last year and had received training in emergency call handling – but was not clinically trained.

The family also raised concerns that the ambulance was originally rerouted to another call – despite being just moments from arriving to Brooke’s aid.

Christopher Hewetson, an EEAST emergency and center support manager, said that when a call is downgraded it goes into a queue of other calls in the same category – with those who have waited the longest prioritised.

But John Revell, Brooke’s uncle, said: “It is frustrating that there was no dynamic risk assessment.

“Surely it would have made much more sense to keep the ambulance on course to an infant who is struggling to breathe and is just around the corner.”

In a statement, Mr Hewetson said the trust had acknowledged that mistakes had been made in the incident.

He added: “We would like to offer our sincerest apologies and our condolences for the family’s loss.”

Giving a narrative conclusion, Mrs Blake said: “The call handler did not recognize Miss Bird was giving CPR which would have made the call category one.”

But she added that there was no medical evidence to suggest that the time lost could have made any difference to whether Brooke could be saved.

Miss Bird added: “I don’t really feel like any real justice has been done – every day is a struggle for us now.”

Timeline of August 17, 2021

11.05am: Miss Bird dials 999 after finding Brooke “floppy” in her cot. She starts CPR

11.06am: The call is initially classified as category one and an ambulance crew is called for

11.07am: The ambulance leaves Sprowston police station, where its crew had been stationed

11.08m: The call is downgraded and the crew, which is already on its way, is rerouted to North Walsham

11.10am: The call is upgraded to category one again and the crew turns around. By this point, Mr Nally is giving first aid instructions

11.12am: The crew arrives at the family address

11.14am: Paramedics take over Brooke’s care. She is treated in an ambulance then taken to hospital

12.07pm: Brooke dies at the Norfolk and Norwich University Hospital

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