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A girl who died of a rare disease waited more than an hour for an ambulance at a GP surgery, an inquest has heard.

Ffion Jones, from Rumney, was taken to her local GP surgery by her mother after complaining of tiredness over a weekend that led to severe vomiting on December 7, 2016.

The 12-year-old was found to have an elevated heart rate, fast breathing and her blood pressure was so low it was unrecordable.

Unbeknown to her family and her GP at the time, Ffion had Addison’s disease, a rare disorder of the adrenal glands.

An inquest into Ffion’s death held at Pontypridd Coroner’s Court on Thursday, heard that a GP requested an emergency eight-minute ambulance to take her to hospital.

Summarising the facts of the case, Assistant Coroner David Regan told the court the ambulance took an hour to arrive, by which time she had collapsed and gone into cardiac arrest.

She was taken to hospital and admitted to a paediatric unit. It was there that it was discovered she was suffering from complications related to Addison’s disease.

Ffion was pronounced dead at the University Hospital of Wales, Cardiff, at 1.31pm the following day.

(Image: UGC)

A statement was read out on behalf of Ffion’s mother Stephanie Jones. Mrs Jones said that in early December Ffion and her family had been away. Ffion has been “her usual, playful self” but had appeared lethargic and tired.

Mrs Jones said she received a call from Ffion’s school on December 5, saying she was feeling sick.

She stayed home the following day with her father the following day but had been vomiting continuously. On the morning of Wednesday, December 7, she said it was clear Ffion had “more than just a simple bug” and they contacted the local GP practice. She was taken to an appointment with Dr Nicola Leeson at Rumney Primary Care Centre at about 2pm the same day.

Giving evidence, Dr Leeson told the court she first saw Ffion outside her office.

“There was a mother and a little girl walking quite slowly down the corridor towards me,” she said. “As they came through the door Ffion said she felt unwell and wanted to lie down on the bed. So we assisted her onto the bed. I actually thought she looked quite unwell.”

Dr Leeson said Ffion’s mother told her she had been vomiting for the past 48 hours, and didn’t have any history of serious medical problems. Under examination, Dr Leeson said she found Ffion’s breathing was elevated, and her heart rate was around 160 beats per minute.

Her blood pressure was so low it wasn’t possible to take a reading. Dr Leeson said she was concerned that Ffion may have been dehydrated by the extended period of vomiting so immediately called for an ambulance.

(Image: UGC)

She told the court she had recently received training that led her to believe the Welsh Ambulance Service wouldn’t provide an eight-minute emergency ambulance to GP surgeries unless it was for a cardiac arrest, choking or hanging incident - or she made the call herself to a special number. Dr Leeson said she made the first call at 2.24pm, but was told she needed to call 999.

She then redialled 999 but was told they couldn’t provide an eight-minute ambulance, but that one would be sent as soon as possible after that.

Dr Leeson then made a call to the paediatrics department at UHW to inform them that Ffion would be arriving and to ask for advice on how to care for her in the interim.

“I was very disappointed to be told on the new system that the operator was unable to send me an eight-minute ambulance as I requested,” she said. “[The operator] did say that she was going down the 999 line and she would arrange one for me quickly.”

She added: “I didn’t get the response I was expecting so I was taken aback.”

Dr Leeson said she kept Ffion lying down and provided her with Dioralyte to drink while they waited for an ambulance. She said Ffion’s condition improved as she started speaking, moving around on the bed and her colour returned.

Dr Leeson said she then left Ffion and her mother with a receptionist while she went to examine other patients. Shortly after 3pm she was informed that Ffion had collapsed.

“I went straight into the room to find Ffion lying on one side,” Dr Leeson said. “She was lying on one side, she was unconscious, her pupils were dilated and she was breathing shallowly.”

Dr Leeson added that she put out a cardiac arrest call and other staff came to help her.

A call was made to the ambulance service to inform them she was in cardiac arrest. “Just as we were applying the oxygen another receptionist appeared to say that I had to go and confirm it was a real cardiac arrest before the ambulance service would send an ambulance,” she said.

“I was obviously slightly distracted by the information I had just been given and was rendered speechless for a few seconds.”

(Image: Mark Lewis)

Dr Leeson explained that the surgery did have an intravenous saline drip on their resuscitation trolley, but she had decided not use it because she had not administered a cannula for many years, and didn’t believe it to be a routine job for a GP to perform.

A statement was read out on behalf of paramedic Matt Taylor, who was the first responder to reach the GP surgery. Mr Taylor said he arrived at the scene at 3.21pm after being allocated the call 10 minutes earlier.

Mr Taylor confirmed cardiac arrest and commenced CPR. Glucose and saline was also administered to Ffion. An ambulance arrived at 3.30pm and took Ffion to UHW at 3.41pm. A pulse was regained on the journey to the hospital. Dr Orungati, consultant at UHW, told the court Ffion was admitted to the hospital on December 7. Throughout her stay there she was unresponsive with her pupils dilated.

At 1.31pm she was pronounced deceased after she failed tests to detect brain activity. Dr Malcolm Gajraj, consultant in paediatric intensive care at UHW, said: “My expectation is that yes if we had treated the hypovolemia we would have reduced the chances of an arrest.”

The inquest, which is expected to last two days, continues.