A pensioner died after spending two hours in agony waiting for an ambulance while lying in a GP surgery car park following a fall, an inquest heard.
Josephine Ellis, 76, had just attended a mobile clinic at the medical centre when she lost her footing on the way to her car.
No blankets were brought out by staff to help keep her warm, despite it being a cold October day, the hearing was told.
It also emerged a call handler who took a second 999 call after her condition deteriorated treated it as ‘an estimated time of arrival call’ instead of re-triaging the patient.
When paramedics finally arrived at Hoveton and Wroxham Medical Centre in Norfolk, they took Mrs Ellis to hospital where she was found to have broken her hip. Her condition worsened and she died three days later.
Coroner Jacqueline Lake halted the inquest on Monday to get more information after the widow’s family raised concerns about her treatment.
In a harrowing statement, Mrs Ellis’s daughter told the hearing: ‘She was left lying on the cold car park floor in severe pain for over two hours before the ambulance arrived.
‘Although she was near a GP surgery, no blankets or other means of warmth were provided.
‘A doctor from the nearby surgery attempted multiple times to lift my mother without adequate support, which caused additional pain and distress.’
Some staff at the medical centre ‘did try to reassure and help her’, she added, with one providing a coat used to prop up her mother’s leg.
Retired soldering technician Mrs Ellis had been to a hearing appointment in the grounds of the medical centre just before 2pm on October 23 when she turned quickly and fell, the inquest heard.
Her daughter, a healthcare assistant, was unable to move her and called 999 at 2.20pm.
But by 4pm Mrs Ellis, who had spent years as a fundraiser for the Royal British Legion and the Royal Navy Association, was still lying in the same spot.
Chris Hewitson, a patient safety specialist officer at the East of England Ambulance Service Trust, told the hearing in a statement that Mrs Ellis was correctly classed as a Category three patient, meaning an emergency crew should be with her within two hours. CAT 3 calls are common for people who have suffered falls.
She was upgraded to a CAT 2 response – which requires a response within 40 minutes – at 3pm following a call from an ambulance service clinician.
The ambulance service received another 999 call at 3.23pm to say Mrs Ellis’s condition had deteriorated but instead of re-triaging, the call handler treated it as an ‘estimate time of arrival call’.
Mr Hewitson said: ‘It is noted that as the caller had stated Mrs Ellis’s condition had worsened, a triage should have been undertaken.
‘We would like to apologise for this omission and feedback has been provided to the call handler.
‘For information, had a re-triage taken place, this would not have affected the response as CAT 2 is the highest category for a patient who has fallen, unless the patent is unconscious.’
The Trust was under ‘significant pressure’ at the time due to the volume of 999 calls it was handling and problems with ambulances dropping patients off at hospital, he added.
But he continued: ‘I appreciate this will offer very little comfort to Mrs Ellis family.’
Mrs Ellis, who lived in Sprowston, was eventually taken to Norfolk and Norwich Hospital in Norwich, where her broken hip was identified with an X-ray.
She had surgery on October 25 but died the following day.
The ambulance trust said it had taken action since her death, including recruiting additional staff and introducing care co-ordination hubs.
The coroner said the inquest would be reopened at a date yet to be set.