Coronial
QLDcommunity

Howlett, Peter David

Deceased

Peter David Howlett

Demographics

44y, male

Coroner

Risson

Date of death

2006-04-21

Finding date

2010-03-25

Cause of death

acute myocardial ischaemia due to coronary artery occlusion due to thrombosis and atherosclerosis

AI-generated summary

Peter Howlett, a 44-year-old male, died of acute myocardial infarction on 21 April 2006 after a 54-minute delay in ambulance arrival. His wife called Triple 0 reporting back pain radiating to chest at 7:20 am. Critical communication failures occurred: the call-taker (Ms Gibson) failed to hear the patient's chest pain symptom and did not escalate to the appropriate cardiac protocol. The supervisor (Ms O'Connor) then improperly downgraded the call from Code 2A to 2B in breach of Standard Operating Procedure 27, which required doubt to be resolved in favour of the original coding. The dispatcher (Ms Protheroe) delayed assigning the call by 22 minutes and selected an inexperienced crew unfamiliar with the local area during a shift changeover, resulting in the crew becoming lost. By the time the ambulance arrived at 8:16 am, the patient was in cardiac arrest. Multiple system failures in dispatch protocols, staff decision-making, and geographic knowledge contributed to preventable delays in critical care.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinecardiology

Error types

communicationdiagnosticsystemdelay

Clinical conditions

acute myocardial infarctioncoronary artery occlusionatherosclerosiscardiac arrest

Contributing factors

  • failure of call-taker to hear and document chest pain symptom
  • improper downgrade of call code from 2A to 2B in breach of Standard Operating Procedure 27
  • delay in dispatch assignment (22 minutes)
  • selection of inexperienced crew unfamiliar with local area
  • crew became lost en route due to poor local knowledge and misleading map reference
  • shift changeover timing influenced crew selection decision
  • failure to prioritise the pending call during crew briefing
  • lack of clinical oversight in communications centre
  • 54-minute delay from initial call to ambulance arrival

Coroner's recommendations

  1. The Queensland Ambulance Service use actual case studies such as the Howlett matter, including playing actual tapes with consent of those involved, in training all staff
Full text
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