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Anoxia Case in Sweden - EMS Foul-up

Hans Christian Eidenert hce at bahnhof.se
Mon Jun 26 10:06:14 EST 1995

This is an attempt to establish if a  911 emergency operator has responded
appropriately to an emergency call and whether such a case would be
handled differently in other countries around the world.

Below please find the background as reported in a local Swedish newspaper
article (translated from Swedish).

SOS Alarm has been charged once again for late ambulance 

Another case where a late ambulance has led to disastrous consequences for
a patient has now led to the indictment of SOS Alarm in Uppsala to the
health and hospital care scrutiny authority. 

The SOS Alarm was called three times according to information given to UNT
but during the first two only second hand information was given.

It was not until 25 minutes after call number one that an ambulance
arrived on location, which is situated at approximately three minutes
driving distance from the ambulance station at the central fire department
station in Uppsala.

Then it was too late - the patient a young woman who had taken an overdose
of painkillers, is now in a coma and she is feared to have suffered from
such brain injury that she will never be able to recover from. 

- Now that we know what has happened we are devastated, says the young
woman¹s  relatives to the newspaper.

It is unclear how serious the emergency operator has construed the
situation during the different calls since the information at least
intitially was insecure. 

- But at the same time the emergency operators should be used to and
educated to receive insecure information and therefore send immediate
emergency assistance to be on the safe side, says the relatives.

The incident occurred during the Easter holiday in Uppsala. The young
woman called two of her friends to indirectly say goodbye. 

Both friends immediately became worried. One friend says that she called
SOS Alarm and told them about the conversation. She said that she believed
that the young woman was committing suicide. She was however asked by the
alarm operator to check further and then get back with more information.

She made various attempts to get in contact with the woman. Whn she did
not manage to contact she called again - five minutes after her first call
to the EMS - to SOS Alarm and asked them to act. She then received the
information ³we¹ll  send a car².

In the meantime the other friend who had been called by the woman had gone
to the location. He found that she was at home but did not manage to get
any contact with her and decided to break in to the house.

This attempt failed, and instead he could climb via a ladder through a
window. After a few minutes search he found the woman unconscious. 

He then called SOS Alarm and asked for an ambulance to the address - this
was approximately eleven minutes after the second phone call in the same

After another four minutes a police patrol arrived to the house and  some
minutes later an ambulance.

The unconscious woman was taken care of and sent to the Akademiska
Hospital, where she according to their information about ten minutes later
- more than half an hour after the first emergency call.

The other day the Socialstyrelsen announced that they insist on
disciplinary action against a alarm operator at SOS Alarm in Uppsala who
reportedly had made a mistaken assessment and wrong priority in connection
with an ambulance request.

The incident took place in January this year. Also in this case SOS Alarm
was called three times, based on second hand information. It was not until
one hour and eleven minutes after the first emergency call that the
ambulance arrived. The patient, a 62 year olc man, was then already dead.

Isn¹t  this a lot of complaints in such a short period of time?

The question is put to Stig Lindberg, director of SOS Alarm in Uppsala.

- It is too much, he says. We cannot allow any mistakes to take place in
our operation. But let the Socialstyrelsen first decide whether we have
done anything wrong.

- Personally, I cannot see that any mistake has been done, says Stig
Lindberg. But I have during my control of the taped emergency calls only
listened to two calls.

- At 11.41 a person called and asked to talk to the police. Nothing was
said about an ambulance and the call was transferred to the police.

- At 12.02 a man called and asked for an ambulance . Two emergency
operators were involved in the case. One of them interviewed and took note
of the address. The other one, the co-listener, made the alarm. After
about thirty seconds an ambulance  was contacted, which means that the SOS
Alarm got a reply from an ambulance which was on its way. 

The medical officer responsible for the ambulance authority Dr. Rolf
Karlsten does not wish to make a comment in the matter until he has
performed his investigation.

One week later the following could be read in the local newspaper UNT.

SOS Alarm did nothing wrong.

- We have not done anything wrong. This is what Stig Lindberg, Director of
SOS Alarm in Uppsala claims after an article in UNT last Friday. The
article claims that a woman has serious injury after a suicide attempt due
to a late ambulance.

All calls to the emergency operator ate taped. Stig Lindberg has now
listened to the tape from Easter Day, when the incident occurred.
According to the article the SOS Alarm are supposed to have received three
calls and the ambulance arrived not until 25 minutes after the first call.

- I have listened to the tape and found that we have only received two
calls, says Stig Lindberg.

At 11.41 a woman called and said that she suspected suicide. The call was
then routinely transferred to the police. We recieve a steady flow of
phone calls and the police has to do an interview before emergency
resources are put into action. The police sent a patrol to the location. 

- At 12.02 a man called SOS Alarm and asked for an ambulance, continues
Stig Lindberg. The ambulance was on its way after about thirty seconds and
arrived to the address two minutes after the police. 

- The woman who claims that she has called us numerous times perhaps does 
not know which emergency center she was talking to but thought that she
was all along talking to SOS Alarm when in fact she was talking to the
police. The Uppsala police department was taking care of the case between
11.41 and 12.02.

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