Firstly, I wish to offer my sincere condolences to the relatives of the person who died. Under the Acute Coronary Syndrome Programme, patients with symptoms and ECG findings indicative of a STEMI-type acute heart attack are treated according to the National STEMI Protocol, which was officially launched in October 2012. It has been in use in the west of Ireland since July 2012. Under the protocol, if patients can be transported to a primary PCI centre providing 24/7 treatment of STEMIs, then they are brought directly to that centre. The primary PCI centre in the west of Ireland is the cardiology centre in University Hospital Galway. This unit has 2 cardiac catheter laboratories and a dedicated team of interventional cardiologists, nursing, technical and radiography staff on call 24/7. Based on international best practice, a unit such as this will serve the population of the west of Ireland for management of STEMI.
If transport to Galway within 90 minutes is not feasible, then STEMI patients are taken to the nearest emergency department equipped to stabilise patients, such as Mayo General or Portiuncula, for thrombolysis (administration of clot-bursting drugs) to stabilise the situation. They are then transferred to UHG for assessment as to whether further immediate intervention is needed. This is accepted international best practice for management of STEMI patients, particularly in remote areas. In addition to the national protocol, the Code STEMI Protocol, approved by the Medical Director of the NAS and through the HSE Clinical Care Programmes, outlines the actions required by hospital and NAS staff when a hospital STEMI patient is to be transferred to a PCI centre.
The incident raised by the Deputy was reported to the National Incident Management Team at national and regional level for review. The Ambulance Service also carried out an internal review and in parallel requested an independent review, which was conducted by the State Claims Agency. A review was also conducted between the Ambulance Service and Mayo General Hospital to ensure that the CODE STEMI protocol is followed for this type of incident.
The outcomes of the reviews have been raised with Prof Kieran Daly, project lead of the Acute Coronary Syndrome Programme, and the Director of the National Ambulance Service, Robert Morton and actions highlighted by these reviews have been implemented. These include training of staff, a written protocol between Mayo General Hospital and the NAS, additional auditing of calls within the Ambulance Control and the recirculation by the NAS of the Code STEMI protocol. Since this incident, all such transfers are treated as an emergency and six STEMIs have occurred in Mayo General, all following the protocol.
In relation the incident itself, the HSE National Ambulance Service has informed me that, at 19:30 on 17 August 2013, the patient began to experience symptoms and, about an hour later, self-presented to Mayo General Hospital Emergency Department, where an ECG was carried out. At 21.06 the National Ambulance Service received a call from Mayo ED to organise an emergency transfer from Mayo to Galway for a patient with a myocardial infarction. However, the patient was described as for angioplasty, not as a Code STEMI, and the CODE STEMI protocol was not initiated. At 21.20, an ambulance was assigned. Mayo ED was notified that an ambulance was en route, but the ED advised that the patient was being thrombolysed and the ambulance was not required.
The NAS has confirmed that there were two ambulances at Mayo General ED at the time of the incident. An ambulance is not available for further duty until the patient is transferred to medical staff in the ED and the ambulance is reported as available. Depending on the previous call, once the hand-over is completed, the ambulance may need to be restocked, refuelled or cleaned before being ready for duty. Both ambulances had responded to previous calls and the hand-over of patients had not been completed at that point. The ambulance based in Castlebar was available and was tasked, in line with the transfer request from the hospital, but was stood down on advice from the hospital.