By Eric Nicolson

AN AMBULANCE called out to a Perthshire woman needing treatment for a stroke that killed her not long after she got to Perth Royal Infirmary took too long to get to her, an independent NHS watchdog has found.

It took an hour more than it should have for the ambulance to reach the woman, a Scottish Public Services ombudsman has decided, and during this time her “condition clearly deteriorated.”

The family of the woman who died raised a number of complaints regarding the delay in diagnosing the woman’s stroke and admitting her to hospital in October 2005.

Those upheld by the ombudsman were:

* The GP failed to stay with the patient while waiting for the ambulance.

* The GP failed to give the case a high priority.

* The ambulance took an unreasonable time to attend.

Complaints not upheld were:

* That NHS 24 failed to make a correct diagnosis despite evidence to indicate that ‘Mrs D’ had suffered a stroke.

* NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance.

* The GP failed to provide a referral note to the hospital.

The ombudsman has recommended that the NHS Tayside board reflect on what lessons can be learned.

It has also been recommended that the Scottish Ambulance Service issues a further apology to the family in respect of the additional delays in responding to the call from the GP and considers reviewing its procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

The two organisations have both accepted the recommendations and will act on them accordingly, it was stated last night.

The family believed their GP called for an ambulance at 10.15pm, and that it did not arrive until 12.30am.

One of them called NHS 24 a number of times to try to hurry the ambulance and the ombudsman said that “during these calls he spoke to at least three different people.”

The ombudsman added, “The ambulance service have stated that they agreed with the out-of-hours GP service that the ambulance would arrive at 12.07am.

“They have since stated that because of the high level of emergency demand the ambulance was only dispatched at 12.08pm and did not reach ‘Mrs D’ until 12.26am, around half an hour late. They have admitted that they failed to respond within the agreed timescales and have apologised to the family for the delay.

“However, having viewed the computer records of the call, it appears that the agreed attendance time was one hour from the time of the call.

“I believe that the service had expected to attend by 11.37pm and had given the time of 12.07am as that of the expected time of arrival at hospital. This would be in agreement with the GP’s view. He had also considered that he had requested attendance within an hour.

“It appears that there was confusion over the scheduled attendance time, with this being documented as being 12.07am, despite the computer records indicating a time by bedside of 11.37pm.

“This apparent confusion in respect of the agreed attendance times added to the delay already admitted by the service of half an hour and led to the ambulance actually attending an hour later than was expected by the GP and family. During this time Mrs D’s condition clearly deteriorated.”