Kenyan Model Died Of Stomach Haemorrhage After Two UK Ambulances Failed To Show Up Through 999 And 111 Blunders

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Linzie

A model died from a rare stomach haemorrhage just hours after she felt unwell, an inquest has heard.

Linzie Mumbi Ngarari, 22, died at home on June 29 last year, less than seven hours after waking with severe stomach pains and sickness. Read more after the cut…
The student, who took part in the Face of Kenya competition in 2013, was told by a paramedic from the 111 service that she was suffering from a stomach bug. But Birmingham Coroner Emma Brown said there had been a ‘missed opportunity’ to send an ambulance because of an error by an emergency call handler.

The court heard how her worried mother Jane had called for the ambulance at 5.15pm, but was directed to the 111 phone service. It emerged during the hearing that the 999 call operator had misheard an answer to one of the key questions, which meant an ambulance was not sent.

Instead of paramedics arriving with half-an-hour, the system said Miss Ngarari should be directed towards the 111 service. There, her mother spoke to a paramedic who told her that her daughter  a third year mechanical engineering student at Birmingham City University was suffering from a stomach bug. It meant that an ambulance was not sent for a second time.

Both of the calls, which included Miss Ngarari moaning in pain as she spoke to operators, were played in court.
An ambulance was only sent to the family home after a further 999 call after 11pm when her mother found her unconscious and unresponsive. Despite CPR attempts by her mother and paramedics who arrived within five minutes, she was pronounced dead at the scene.

Consultant Pathologist Jerrard Langham told the inquest that Miss Ngarari died as a result of a spontaneous haemorrhage in her stomach.

‘This is a very uncommon event,’ he added. ‘We do see it in some traumas like car accidents and in ectopic pregnancies, but there was no obvious cause in this case.’

Mr Langham said it was unlikely Miss Ngarari would have been saved even if she had been taken to hospital because of the short time between her first symptoms and her death.

Miss Ngarari said her daughter had attended a yoga class on the Sunday morning as normal, describing her as ‘completely fit and healthy’. Jason Wiles, head of patient safety with West Midlands Ambulance Service, told the court that he had been appointed to review the case.

He said six recommendations have been made, including extra training for call handlers around probing more during questioning and continuing to question until clear answers are given. There had also been changes to the way pain is assessed and details of the case had been shared nationally.

The coroner recorded Miss Ngarari died from natural causes.