01 July 2023 , 11:14
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A pregnant nurse bled to death at home more than four hours after she called for an ambulance, an inquest heard.
Stabile Sibanda called 999 at 1.11am on July 23 last year and told the call handler she was having abdominal pain and thought she was having an ectopic pregnancy.
South Central Ambulance Service (SCAS) was “very busy” and dealing with high levels of post-Covid staff sickness due to poor mental health, an inquest at Reading Coroner's Court heard.
A private ambulance service called Phoenix was used, but the crew they dispatched did not include a trained paramedic.
Phoenix technicians Kara Mathieson and Lee Brown arrived at Ms Sibanda’s road in Ascot, Berkshire, two hours after the initial call at 3.11am.
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But could not locate her first-floor flat until 27 minutes later.
The pregnant nurse bled to death at her home in Ascot, Berkshire (Facebook)The technicians said the 28-year-old was “combative and lashing out” on their arrival.
Mr Brown said she was being “obstructive” by throwing herself on the floor as they tried to get her into the ambulance.
They “very quickly ruled out” the possibility of an ectopic pregnancy and decided Ms Sibanda was on drugs and had been sexually assaulted, the coroner found.
The Phoenix crew called the police at 4.36am for assistance in getting Ms Sibanda into the ambulance but she suffered a haemorrhage and was declared dead at 5.33am.
Ms Mathieson denied knowing Ms Sibanda was having an ectopic pregnancy, telling the inquest Ms Sibanda had stated she last had sexual activity three years ago.
A SCAS call handler had told Ms Mathieson the case was a suspected ectopic pregnancy, but she told the inquest “she was closing an ambulance door at the time” so did not hear the information.
Mr Brown also told the inquest this week he did not know about the ectopic pregnancy, despite making a statement last year in which he admitted Ms Sibanda had told them she was having one.
The Berkshire Coroner Heidi Connor said she was “deeply concerned” about the evidence given by the two Phoenix technicians.
“Sometimes we think about events, particularly stressful events and think about what we wish we had done”, Mrs Connor said. “There are however stark differences in their statements.
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“I find it likely that first crew were told by Ms Sibanda that she was having an ectopic pregnancy. The first crew remained blindsided by her difficult presentation and made assumptions about the likely cause.
“If they had been considering ectopic pregnancy, that would have focussed their minds more on getting her to hospital.”
Mrs Connor said the clinical governance lead at Phoenix had told the inquest there were no significant learning points which arose from Ms Sibanda’s death.
“I was concerned to note the somewhat defensive approach taken”, the coroner said.
“Those involved in contracting private providers were in attendance at the inquest and it is for them to consider whether they are sufficiently assured by the approach to learning taken by Phoenix.”
Ms Sibanda only lived a 20 minute drive away from the nearest hospital, but she would have needed to have been taken into surgery very quickly after reporting her condition, the coroner said.
Therefore it was not possible to conclude the delays caused or contributed to Ms Sibanda’s death and the coroner concluded she died of “natural causes”.
Ms Sibanda had come to the UK from Zimbabwe only a few weeks before her death to work as a nurse, Reading Coroners Court heard on Friday.