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Parents struggle to get truth about son's death

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Avril and Robert Bandy's 30-year-old son Keith died as a consequence of the negligence of the East Midlands Ambulance Service NHS Trust.

The Bandy's had compelling evidence to support that contention, yet it took three years to persuade the Coroner to hold an inquest after Keith's death had been ascribed to 'natural causes'.  The parents struggled for many more months against the obfuscation and bureaucracy that thwarted their attempts to get at the truth, which is why in the end they felt they had no option but to go to the law.

Keith had struggled with asthma and upper respiratory tract infections all his life and was on a substantial amount of medication. He also frequently suffered chest tightness and used a peak flow meter regularly to check on his breathing and the efficiency of his lungs.

He had moved out of his rented flat and had been living with his mother Avril in her bungalow for three weeks before he died. Avril had separated from her husband Robert, but the couple remained on good terms and Robert took an active role in Keith's life and his care.

On 22 May 2010 Avril returned home from working a night shift at the hospital. She noticed that the kitchen curtains were not drawn, which was unusual and when she unlocked the back door, the family dog could not get outside quickly enough. She wondered if Keith had been too unwell to let the dog out earlier (Keith had a vomiting bug the day before).  It was then that she found her son kneeling slumped up against the fold up bed he used in the lounge.

Avril called 999 and told the operator Keith was not breathing. She was advised to start CPR, and told the operator she would have to unlock the front door first so that the paramedics could get in, as she knew from her nursing training that once she had started CPR, she would be unable to stop.  However, when she went to unlock the front door she found the keys were in the lock and the door was already unlocked. That too was unusual, but its significance would only become clear later.

The ambulance arrived and two paramedics entered the house. They took over the CPR but Avril could not bear to watch them because she already suspected it would not work. She called relatives and when they drove up to the house she saw them coming on the CCTV she had installed, so was able to open the door as they arrived and ushered them into the lounge.

Her former husband Robert and his wife arrived soon after and Avril showed him into the lounge where the paramedics were still attempting CPR.  By 08:30 the paramedics had been carrying out CPR for over half an hour but it was obvious that they were not going to bring Keith back. They stopped CPR and pronounced him dead.

While the paramedics were packing up, Avril confided to her other son her suspicions that something was not right:  the front door had been unlocked and it looked as if someone had been in the house.  She even speculated that perhaps somebody had come in and assaulted Keith. It was then she remembered the CCTV security cameras installed in the property.

Two cameras covered the front door and drive and another two covered the back garden. Checking the footage which was time and date stamped would confirm if someone had been in the house. It was only then that the attending paramedics told her that in fact there had been a previous emergency call out – the first she had known about it.

Keith apparently rang 999 earlier in that morning. A paramedic had arrived shortly after that call and allegedly asked Keith to stand up and blow into the peak-flow meter. It seems Keith did not comply with that request probably because he was too ill and could not do as he'd been asked. The paramedic then left after only a few minutes without treating him and completed the Patient Referral Form stating that he left without treating Keith as he was being was 'uncooperative'.

The first paramedic later claimed in his evidence to the internal enquiry (and at the inquest that was eventually convened) that he had taken into the house all the correct equipment and had attended Keith for some time, going so far as to alter the time of his arrival in the records. However, the CCTV footage revealed the true brevity of his visit and clearly showed that he did not have the equipment he claimed to have taken.

Avril contacted the Coroner's office who advised her that, following a post mortem, Keith's death was ascribed to natural causes and there would not be an inquest. The Coroner released the body and she had to go to the police station to pick up some forms in order to obtain the death certificate.  

In the meantime, in light of the evidence on CCTV which directly contradicted the paramedic's account of how long he had been there, Avril had written the first of many letters to the East Midlands Ambulance Service.  At first she was told that they were 'dealing with her complaint', but a month later she was informed the investigation had been unavoidably delayed, without giving any reason for the delay.

Avril was also in correspondence with the Coroner asking for clarification of the reasons for not holding an inquest. She advised the Coroner of the delay in the EMAS investigation and received a reply which included the statement of the paramedic who had first attended Keith and the patient report from EMAS.

Based on the information in those documents, the Coroner had concluded that there was no need for an inquest because there was no evidence of neglect. Avril was distraught. The CCTV footage alone showed that the documents and statements were at best an incomplete or ill-informed version of events and at worst a deliberate attempt to disguise the truth.

Jill Davies, a solicitor with Access Legal specialising in medical negligence who took on this case commented:

'Avril's knowledge of her son's condition, her own nursing training and the evidence of the CCTV made it clear that the 'official' version of events was seriously flawed. It also angered her that the first paramedic, who would retire shortly from the service, would be leaving EMAS without being held accountable in any way whatsoever.'

The task of constantly writing letters and putting in phone calls to the Coroner and EMAS was beginning to prove too stressful for her, so Robert took on the task of trying to get those bodies to respond. After three years of trying and with the help of patient charity AvMA, the family eventually persuaded the Coroner to hold an inquest.

They were represented pro bono (i.e., free of charge) by a barrister, Paul Reynolds who along with his colleague, Kate Beattie, was consistently helpful to both the family and later their solicitors Access Legal as the case developed.

The inquest concluded that the paramedic who had attended at first failed to test Keith's oxygen levels, despite his breathing problems. The paramedic also failed to consider whether Keith was hypoxic, failed to record his visit properly and left without providing treatment. The Coroner concluded that, on balance, had their son been appropriately treated, he would have survived.

The Coroner also indicated that she would be writing to the East Midlands Ambulance Service recommending that they draw up improved guidelines setting out what equipment paramedics should bring in the first instance when attending a patient.

After the inquest verdict Avril and Robert felt vindicated to some extent, but also extremely disappointed. Avril comments:

'When the Coroner supported our version of events we felt relief of course. We were so desperate to clear Keith's name and expunge from the records any suggestion that he had been uncooperative.  We were also left feeling that EMAS had strung out everything deliberately and it just felt like they had put us through hell, yet they got to walk away without any kind of sanction.'

It was immediately after the inquest that Avril and Robert turned to Access Legal for help. Jill explains:

'Frankly the Bandy's needed to claim to cover the sums, which they could ill afford, that they'd had to spend on the funeral, the headstone and the years of trying to get at the truth without any aid or assistance. Above all though they wanted to achieve some sense of justice for their son. There were still many unanswered questions hanging in the air and they wanted a more public admission of fault by the EMAS, if only to prevent the same thing happening to others in future.'

She continues:

'The problem was the three year time limit for bringing claims in cases like this had elapsed. The time was eaten up by the fact that the EMAS missed many deadlines as well as the years it took the family to fight for an Inquest. Ordinarily, many other solicitors would have refused to look at the case given the expiry of the time limit, but we were so moved by Avril's story and impressed by her determination that we agreed to take the case on.'

The compensation award finally granted covered only the costs of funeral and other expenses the family had incurred, which is not unusual in cases of fatal injury where the victim had no dependents and whose own pain and suffering prior to death was brief.  However, to add insult to injury, as a result of recent interpretations of the legal rules about claims made by secondary victims, neither parent could make a claim for the considerable psychological trauma they unquestionably suffered.

At the end of the day, the family at least achieved most of what they wanted. They were reimbursed for the expenditure associated with the funeral, they got closer to the truth and any suggestion that Keith was somehow uncooperative was shown to be false. However, although the East Midlands Ambulance Service effectively admitted responsibility for Keith's death, to his parents' knowledge the first paramedic was never censured in any way.

Avril Bandy concludes:

'We want to thank Jill in particular for all her help. The fact that Access Legal took us on when it was likely that no one else would is also greatly appreciated. There are still some regrets and questions. Why did it take so long to get justice and why were we continually blocked and fobbed off with excuses and delays? If the EMAS had been more open and forthcoming at the start we would not have had to go to law to get answers, but ultimately I'm glad we did.'

Read more about this story in the Sunday Express and the Northampton Chronicle & Echo

Listen to Jill Davies talk about Avril's story and how Access Legal helped the Bandy family in a Sunrise Radio interview.

 

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