Coroner details care 'failings' over Mthuthuzeli Mpongwana meningitis death


A coroner has said there was a "missed opportunity" to deliver vital treatment to a man who died from meningitis after waiting nearly six hours for an ambulance. 

Mthuthuzeli Mpongwana, 38, of Bedminster, Bristol, died in hospital two days after his wife, Lisa Armitage, 27, dialled the medical advice number 111.

Ms Armitage called the number at 10.30pm on January 5, reporting her husband was suffering from a sore neck, struggled to look at light and had a bad headache.

She was advised to wait outside her home as a rapid response vehicle with blue lights on would attend, and warned her husband could have meningitis. 

Avon Coroners Court heard the car did not arrive until 1.17am and paramedic Dana Noriega initially dismissed Mr Mpongwana's symptoms as "man flu".

Mr Noriega failed to spot Mr Mpongwana had signs of both sepsis and meningitis and downgraded the case to a 40 minute response at 1.50am.

He did not administer penicillin - which should have been given as soon as possible - until 3.30am and only requested a high-priority ambulance at 3.50am.

The ambulance finally arrived at 4.20am, by which time Mr Mpongwana's condition had deteriorated. He suffered a brain injury and died in hospital the following day.

Maria Voisin, senior coroner for Avon, reached a narrative conclusion at the inquest, in Flax Bourton, near Bristol, and ruled there were "failings" in his care.

"Mr Mpongwana died from natural causes contributed to by a failure to take appropriate action in the face of an obvious need," Ms Voisin said.

"That failure was at 1.50am on January 6, when a P1 (high priority ambulance) backup should have been requested and benzylpenicillin should have been administered. 

"The inappropriate care that was given resulted in a missed opportunity for medical treatment to be given."

Ms Voisin said she did not consider South Western Ambulance Service NHS Foundation Trust needed to take further action.

The inquest heard Mr Noriega has left the trust since the incident.

Mr Mpongwana's wife called 111 at 10.30pm on January 5 after her husband complained that light from his mobile phone was hurting his eyes.

The call was passed to the 999 service at 10.56pm, marked as a P2 - priority two - call, requiring a 30-minute response and checks on Mr Mpongwana's condition every 30 minutes.

However, the ambulance service was busy that evening and only one such "welfare check" took place, at 11.36pm, before any paramedics arrived.

Mr Noriega arrived at 1.17am, as Ms Armitage was calling 999, and took a set of observations.

"Mr Mpongwana's symptoms included a headache, light affecting his eyes and a fever," Ms Voisin said.

"By the time the paramedic arrived he had also been sick and was finding it hard to stand.

"Regardless, Mr Noriega said that at 1.51am he requested a P3 vehicle and not a P1. He said this was because they were busy that night and he thought a P3 might get Mr Mpongwana to hospital quicker."

Mr Noriega failed to administer benzylpenicillin until it was suggested by an out-of-hours doctor he called for advice at 3.11am.

He did not give Mr Mpongwana the drug until 3.30am and failed to call for a P1 ambulance, which would arrive in 15 minutes, until 3.50am.

In interviews with South Western Ambulance Service following the tragedy, Mr Noriega described Mr Mpongwana's condition as "typical man flu", the coroner said.

The ambulance did not arrive until 4.20am and reached Bristol Royal Infirmary at 4.46am. Mr Mpongwana had suffered a fatal brain injury and could not be saved.

Dr Dan Freshwater-Turner, said the outcome might have been different if penicillin had been administered and Mr Mpongwana had been taken to hospital earlier.

The consultant told the inquest: "We will always advise giving antibiotics as early as possible.

"It is possible if he had had treatment earlier that the outcome may have been different."

In a statement read to the inquest, Ms Armitage said: "I told the ambulance service my husband's condition was deteriorating.

"While I was on the phone, a paramedic arrived in a rapid response vehicle.

"I explained Mthuthuzeli had developed a severe headache which had worsened throughout the day. His neck was stiff and his limbs were sore.

"I remember that the paramedic took my husband's blood pressure before telling me my husband had man flu and didn't have to go to A&E.

"I was under the impression he thought my call had been a waste of time."

Mr Noriega told the inquest Mr Mpongwana's symptoms were "red flags" for meningitis and he should have been taken straight to hospital.

The paramedic admitted he had been "exhausted" after working over the busy Christmas and new year period, with strains on his family life.

"I said I didn't want them to be stuck in a hospital corridor if it was flu or something like that," he added.

"I didn't use the term meningitis so as not to worry them."

Mr Noriega said he felt Mr Mpongwana initially seemed to improve after he administered paracetamol, put him in lighter bedding and opened the window.

He claimed he downgraded the call from a priority two call to a priority three to "buck the system" and get an ambulance there quicker.

"They said everybody was committed," he said. "I tried to think outside of the box until they sent someone down."

Mr Noriega admitted that was the "wrong decision" and "taking a risk", following questioning from Ms Voisin.

Speaking after the inquest, Ms Armitage said: "Mthuthuzeli and I had just settled into our new life in the UK together and he had just started applying for jobs.

"When he died I was working as a theatre assistant at St Michael's Hospital but have not been able to return to work as I find it too distressing seeing people having surgery as it reminds me of watching my husband lying motionless on a life support machine.

"I am extremely concerned about the treatment he received by the ambulance staff and I was baffled at the time that they didn't seem to be taking into consideration his symptoms and the urgency of his situation.

"I am still amazed now that the paramedics took such a long time to realise the red flag symptoms of meningitis that Mthuthuzeli was experiencing and it took them six hours to send an ambulance.

"It is incredibly well known that you have to act quickly if someone starts to suffer from symptoms of meningitis and his death could have been avoided if they had taken the care and attention to give him the medical care he rightly deserved."

Ms Armitage was represented throughout the hearing by Julie Lewis, a partner and specialist medical negligence lawyer at Irwin Mitchell.

"The family would like reassurances by the trust to ensure that all their staff are fully trained to notice and diagnose the symptoms of meningitis to prevent anyone else suffering from any similar issues," she said.

"Sadly on this occasion the paramedics didn't seem to recognize the symptoms of meningitis and should have followed the basic guidelines on treating someone with suspected meningitis and Lisa has suffered the consequences."

A serious incident report carried out following the death also found Mr Noriega was not familiar with guidelines for recognising and treating sepsis and meningitis. 

Sue Davie, chief executive at Meningitis Now, said: "Our thoughts are with Lisa and her family at this sad time.

"We know how quickly meningitis strikes and the devastation it causes. Meningitis is often difficult to diagnose, which is why at Meningitis Now, we work tirelessly to raise awareness and educate on the signs and symptoms, and provide lifelong support to families who are trying to cope with the impact of this horrific disease."

A spokesman for South Western Ambulance Service NHS Foundation Trust (SWASFT) said it was "very sorry for the unacceptable delays Mr Mpongwana suffered".

"While demand for ambulance services was at unprecedented levels at the time, a number of improvements have been identified, especially around requests for back-up from clinicians on scene with patients who need to be transported to hospital," he said.

"A number of training requirements were also identified for the paramedic who was first to arrive with Mr Mpongwana and, following a clear process with our HR department, the paramedic's employment with SWASFT was terminated.

"The case has been referred to the Health Care Professions Council.

"SWASFT strives to deliver excellent patient care as quickly as possible and we are very sorry this did not happen on this occasion.

"We would like to offer our sincere condolences to Mr Mpongwana's family."