Pauline Austin, 71, from Tooting, was left waiting hours for an ambulance that she and her carers didn’t know had been cancelled.
Eventually, she lost conscious and staff at her east London care home – which she had moved into just months earlier – dialled 999 a second time.
But by the time she arrived at Whipps Cross Hospital – around eight hours after the initial 999 call – she had suffered a bleed on the brain so “catastrophic” that a stroke expert said it was “not compatible with survival”.
Born in British Guyana, Mrs Austin worked for 21 years as a Bank of England administrator and also had jobs in the civil service and at Bank of America.
She was “funny, generous and always cared about how others viewed her,” her daughter Rebecca told an inquest at East London Coroner’s Court, Walthamstow.
But after being made redundant from Bank of America, her mental health deteriorated. She became “reclusive” and “would create conspiracies in her head, hear music and voices that weren’t present”.
Hip operations at Blackheath and Lewisham hospitals left her with mobility problems, the court was told, and in 2021 she was diagnosed with dementia.
In December 2023, Mrs Austin moved to Harts House care home in Harts Grove, Woodford Green, to be near Rebecca.
In March 2024, Rebecca and her partner went on a week’s holiday and returned to find Mrs Austin in a worse condition than when they left, she said in a statement.
Mrs Austin’s “speech had got worse”. She “couldn’t follow sentences”, had developed a tremor leaving her unable to grip objects or feed herself.
On April 18, she began vomiting, which continued throughout April 19.
Staff dialled 999 to request an ambulance at 4.52pm, but none were available.
The London Ambulance Service (LAS) said the wait for an ambulance was around two hours.
But, in what coroner Dr Shirley Radcliffe called “almost an unbelievable coincidence”, the care home had also recently called an ambulance for another elderly resident on a different story of the building.
A member of LAS staff noticed two calls to the same address and wrongly assumed it was a “duplicate”, so cancelled one – which turned out to have been the one for Mrs Austin.
But testifying on behalf of London Ambulance Service, head of quality assurance control services Sue Watkins told the court the decision to send an ambulance in the first place had been an error.
She said Mrs Austin’s symptoms at that time – nausea and high blood pressure – would likely have resulted in a referral to NHS 111 for advice, and an ambulance was only requested because the call handler mistakenly thought the care home worker was a visiting medical professional.
Around five hours later, Mrs Austin was found unconscious with “fixed and dilated” pupils.
By the time she reached hospital, stroke expert Dr Robert Simister said, there was “no reversible treatment”.
But her symptoms as the day unfolded had been “consistent with a developing intracranial haemorrhage”, he said.
Had Mrs Austin been treated sooner, said Dr Radcliffe, her death “may have been avoided”.
“But we can’t say, on the balance of probabilities, it would have been avoided,” she added. “It was a very significant bleed that was found when she was admitted to Whipps Cross Hospital.”
Either way, the coroner said, the mistake which saw the original ambulance cancelled should not have happened and “there is a risk that that could happen in a case where it could make a big, significant difference”.
Mrs Watkins said the ambulance service had distributed guidance to all staff to check the details of possible duplicate calls before deleting one of them.
She added that the service hoped to soon update its computer system to remind staff to check details before allowing them to delete calls.
“Humans are humans,” she said. “There are errors that will occur.”
Attributing Mrs Austin’s death to “natural causes”, Dr Radcliffe gave her condolences to the family.
“She clearly was very much of a loved one, having been moved to a care home so that you could visit her every day,” she said.
