Systemic failings in the ambulance and healthcare service contributed to the death of a young Belfast man who waited almost four hours for paramedics, an inquest has heard.
Neil Sinclair, the ambulance service’s chief paramedic officer, agreed that a failure to properly categorise the condition of 25-year-old Lee Gannon had led to his death.
He told an inquest into Mr Gannon’s death that the actions of the service had fallen below standard and had “tragic consequences” for Lee and his family.
Mr Gannon died in Belfast’s Royal Victoria Hospital (RVH) after he became unwell in February 2022. A post-mortem examination found he died from lobar pneumonia – a severe bacterial infection.
His family called for an ambulance after he had been unwell for several days and began experiencing breathing difficulties at his home in the Beechmount area of west Belfast.
However, the inquest heard the call was not deemed as a high priority Category 1 emergency and Mr Gannon did not reach hospital for hours after the initial 999 call.
Mr Sinclair said problems with ambulances handing over patients to emergency departments had increased, with crews being forced to wait outside hospitals for hours until there was capacity inside.
This meant greater risk for other people in need of ambulances and the type of “patient harm” which had been seen in Lee Gannon’s case, he said.
He offered sincere apologies for the actions of the ambulance service.
‘Error of misunderstanding’
Earlier, an ambulance call handler who dealt with the first 999 call said she should have given it a higher priority for an emergency response.
Emergency medical dispatcher (EMD) Zena Gardner agreed with reviews of the incident which said it should have been Category 1.
Mr Gannon’s mother Anne had dialled 999 after midnight and reported that her son was having breathing issues, “could barely get words out” and was speaking “gibberish”.
Ms Gardner said the report of breathing difficulties had led her to code the call in relation to coronavirus symptoms, making it a Category 2 call.
Asked if entering an “ineffective breathing” code in the system would have escalated the call to Category 1, she said: “Yes, that’s right.”
“I should have made it a Category 1,” she said.
The ambulance service worker was asked why she had not done that, to which she responded: “I don’t know why I didn’t… it was an error of misunderstanding.”
The inquest previously heard that Mr Gannon would probably have survived if he had been treated more promptly.
However, following the 999 call at 12:19am, the deceased did not reach the RVH until 04:13, where he was later pronounced dead from cardiac arrest as a result of his severe bacterial infection.
Ms Gardner said the ambulance service had been under significant pressure on the night and told the court the situation had subsequently become worse, with waiting times becoming much longer.
She said emergency callers were now regularly advising callers to take relatives to hospital by car if it was appropriate to do so, so they could be treated much more quickly.
Another emergency call handler, Andrea Hunter, told the inquest that she had taken a subsequent 999 call from Mr Gannon’s mother, who said her son’s breathing was getting worse.
She said she should have reacted to the report of deteriorated breathing and re-triaged (reassessed) his condition.
“I should have re-triaged at that stage – definitely… I regret not re-triaging that call,” she said.
When an ambulance had still not arrived, Ms Gannon phoned 999 for a fourth time at 3.26am.
The emergency call handler, James Bryant, told the inquest that Ms Gannon said her son was deteriorating, was dehydrated and was acting very unusually, reeling around on the floor and his eyes were rolling in his head.
Mr Bryant noted that the patient’s condition was getting worse which prompted him to re-triage.
He focused on the patient’s abnormal behaviour, which generated a lower response category, although the system also retained the higher category response in tandem.
Findings at later date
A special case review audit found that when the patient’s mother said he was not responding, it would have been appropriate for the emergency medical dispatcher to clarify if the patient was awake, which could have triggered a different response.
The court heard that training has since been provided around re-triage, including clarification on breathing and alertness and EMDs are encouraged to be alert to new information.
A paramedic, Eamonn Cunningham, who subsequently attended the scene, said he discovered Mr Gannon lying on the living room floor, with his father Colum Wilson, trying to revive him with CPR.
He said there was no pulse, and Mr Gannon was taken to the nearby RVH, but he could not be saved.
The inquest concluded on Tuesday after two days of evidence and coroner Maria Dougan will deliver her findings at a later date.
