Baby Death – Ambulance Crew Failings

Four-month-old Lacey Marie Poton died following a series of regrettable events involving Bristol Hospital and South Western Ambulance Service.

What Happened?

Lacey was fitted with a cardiac catheter at Bristol Hospital. The next day, Lacey was sent home.

Upon arriving home, her mother noticed that Lacey looked ill, and rang the hospital. She received instructions to take Lacey to the family GP, but was told at the practice to rush Lacey into A&E.

A registrar cardiologist at the A&E department of Bristol Hospital did not agree that Lacey should be admitted, and the four-month old was sent home.

Within 10 minutes of returning home, Lacey suffered what is suspected to have been a cardiac arrest, and an ambulance was called.


The ambulance crew did not treat the case as an emergency, and blue lights were not used at any stage of the journey – meaning prolonged travel times.

Suitable monitoring equipment was not on board the vehicle, and the student paramedic tasked with taking notes – for the eyes of hospital staff – did not produce a sufficient recording of events.

Furthermore, the hospital was not made aware of Lacey’s imminent arrival, and 45 minutes passed before a cardiologist was available.

Lacey died early the next day.

Following these events, the lead paramedic has been retained on “restricted practice” – he is not able to provide medical services without the supervision of a senior colleague.

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