“When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it…”

The coroner’s concerns

– (1) When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it was accepted that he explicitly indicated to the Call Handler that the deceased had taken an overdose of, inter alia, tablets. Based upon that, & answers to other questions posed by the call handler, the call handler selected a protocol which did not appear to require this crucial piece of information to be either recorded within it, or to form part of the material which led to the categorisation of the call for the purposes of determing the appropriate response. In short, it led to a categorisation which could only loosely provide a response (based upon the level of demand that evening) estimate of around 3 hours. The concern here is that treatment for a massive overdose is time critical, & the processing of the call did not appear to accurately reflect the peril the deceased was then in, nor the importance of providing an acute emergency response. (2) There appeared to be an opportunity shortly following the initial categorisation of the response, by a clinical floor walker, to upgrade to a code/categorisation which would likely have led to a swifter response, but an under-appreciation, or otherwise, of the then time critical treatment window open to the deceased. I was inf ormed in evidence that the clinical floor walker would have had access to TOXBASE via the Clinical Support Desk at that time, & had that been accessed & inf ormation promptly secured regarding the treatment indicated, this would have alerted the clinician to the need for an acute emergency response. This was subsequently undertaken by the attending paramedic (albeit not via TOXBASE) some hours later, & who immediately after having accessed the treatments for massive overdose, appreciated that the deceased was a time sensitive patient & to convey to the emergency department with all haste. (3) Following the second call to Clinical Contact Centre at 23.48 on 28.10.20, there were somewhat bewilderingly complex, & inconsistent categorisations of the code for response which appeared to lead to response vehicles being despatched or stood down, whilst the patient remained in need of time sensitive treatment by way of transfer to an Accident & Emergency Unit. Whilst I was assured that this had been addressed by learning & guidance to call handlers, a review of categorisations, coding’s & actions in the setting of a patient demonstrating the symptoms as per the deceased on 28/29 October 2020 to achieve clarity/consistency is invited.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0037

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0