A talented football star died aged 17 after 999 call operators failed to recognize a telltale breathing pattern that is a known sign of cardiac arrest.
Adam Ankers collapsed leaving the field after playing for Wycombe Wanderers’ under-19 team in January.
Someone at the scene called an ambulance, explaining that the teenager had collapsed, initially thinking he had suffered a seizure. before explaining that he suffered from “weak” and “sporadic” breathing.
This pattern is medically known as “agonal breathing” and describes when a patient does not receive enough oxygen and gasps for air. It is a known warning sign of cardiac arrest – when the heart suddenly stops pumping blood around the body.
However, the 999 call operator missed this red flag and instead followed instructions to treat a seizure, rather than a fatal heart rhythm problem.
As a result, ambulance crews did not perform life-saving CPR until about 30 minutes later.
At that time, he had suffered significant brain damage. Adam was taken to Harefield Hospital in London, where he was diagnosed with brain stem death, when a person connected to an artificial life support machine no longer has any function.
A few days later, his family agreed to have him taken off life support.
Someone at the scene called an ambulance and explained that the teenager, in the photo, was suffering from “weak” and “sporadic” breathing.
An incident investigation into his death by the South Central Ambulance Service (SCAS) Foundation revealed there was a possible missed opportunity to start life support sooner. Health Services Journal Report.
His death has highlighted a possible recurring problem in the 999 rating and rating system, which is now being reviewed following the tragedy.
The 17-year-old was found to have an inherited heart condition, arrhythmogenic right ventricular cardiomyopathy, a condition believed to be responsible for approximately 600 sudden deaths a year in adolescents and young adults.
While fatal, the condition often goes unnoticed as it does not always cause symptoms in the early stages. However, some patients experience palpitations and fainting.
Adam’s father, Alastair Ankers, an anaesthetist, believes that if his son had been resuscitated sooner he would have had a better chance of recovering.
He told MailOnline: “From the beginning, when Adam was still in hospital, I realized that there were things that hadn’t gone so well that day.
«The most important thing is that there was an eight-minute delay in the start of resuscitation. We know that not starting it quickly is linked to worse outcomes for patients with brainstem injuries.’
According to Ankers, call handlers did not advise bystanders who made the 999 call to use a defibrillator. Unfortunately, there was one nearby, on the soccer field grounds.
The SCAS incident report says a potential opportunity to initiate CPR was missed from 2.36pm onwards, just eight minutes before ambulance staff arrived (file image)
“If someone is unconscious, unresponsive and breathing abnormally, CPR should be started, and that includes defibrillation,” Mr Ankers said. “On that day, this did not happen.”
This is not the first time NHS Pathways (the guide used by handlers to identify emergency problems) has had trouble detecting this irregular breathing pattern, which requires immediate CPR.
HSJ reported that in 2019 there were six cases where concerns were raised, including two where coroners issued reports calling for changes to prevent future deaths.
Some changes were made to try to address agonal breathing issues in 2022, but Ankers’ case raises more questions.
Since the teenager’s death, SCAS has written to NHS England calling for a national review of the system.
SCAS said: “The trust recognizes that Adam’s death at such a young age is tragic and has had a profound effect on his family and friends. “We offer our deepest condolences to everyone affected by his death.
‘As part of our internal review, we have shared the case with the national NHS Pathways team so they can review whether any changes to the triage algorithm are required. We are waiting for your response to this. We have produced new training materials for our call center staff on the importance of re-checking previous answers to system questions when new information is provided that may alter the course of classification.’
NHSE said NHS Pathways, whose processes are overseen by a clinical committee, was reviewing the case, although it had not yet responded to SCAS’ inquiry. He added: ‘We understand the challenges of recognizing agonal breathing and additional training resources on this are provided to services using NHS Pathways.
“We are working with partner organizations across the NHS to ensure we respond appropriately to feedback and support improvements to the system where appropriate, including improving agonal breathing content in 2022.”
An inquest into Mr Ankers’ death is expected to take place later this year.