An inquest at Reading Coroner’s Court (UK) heard that a Zimbabwean pregnant nurse, Stabile Sibanda, bled to death at home more than four hours after calling for an ambulance.
Sibanda had called 999 at 1:11 AM on July 23, 2020, to report abdominal pain and suspected an ectopic pregnancy, The Mirror reported. However, the South Central Ambulance Service (SCAS) was too busy and dealing with high levels of post-COVID staff sickness due to poor mental health.
A private ambulance service, Phoenix, was then called, but the crew dispatched did not include a trained paramedic. Phoenix technicians, Kara Mathieson and Lee Brown, arrived at Sibanda’s home in Ascot, Berkshire, two hours after the initial call at 3:11 AM. They could not locate her first-floor flat until 27 minutes later. Ms Sibanda bled to death at her home, and the Phoenix crew called the police at 4:36 AM for assistance in getting her into the ambulance. However, she suffered a haemorrhage and was declared dead at 5:33 AM.
The Berkshire Coroner Heidi Connor concluded that Ms Sibanda died of natural causes and that the delays did not cause or contribute to her death. She said:
Sometimes we think about events, particularly stressful events and think about what we wish we had done. There are however stark differences in their statements.
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.
During the inquest at Reading Coroner’s Court, Mrs Connor raised concerns about the defensive approach taken by the clinical governance lead at Phoenix, who claimed that there were no significant learning points from Stabile Sibanda’s death. She highlighted that those involved in contracting private providers should consider whether they are confident in the approach to learning taken by Phoenix.
The coroner noted that Ms Sibanda lived within a 20-minute drive from the nearest hospital, but she would have required quick surgery after reporting her condition. Therefore, the delays did not cause or contribute to her death, which was deemed to be due to natural causes.
Ms Sibanda had recently migrated to the UK from Zimbabwe to work as a nurse.