Gary Million

“Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance.”

“No 111/ambulance dispatch staff knew of or had been trained about the correct procedure to be adopted when trying to locate a potentially seriously ill patient when they had incomplete information as to that persons whereabouts. In short, they did not know how to obtain the callers address.”

“When the ambulance service duty manager spoke to BT, that individual did not fully explain the nature and reason for the enquiry with the result that the BT operator was not seized of all relevant information with which he could make a fully reasoned decision as to whether to exercise his discretion or not to release the deceased's home address to the caller.”

“A detailed investigation that was undertaken by North East Ambulance Trust is upon closer examination, in places lacking depth and incisiveness.”

“New revised North East Ambulance Service Trust protocols which are undated, and which were produced to the Senior Coroner only on the morning of the Inquest being resumed, do not deal with the problems identified in this case even though they were designed to address them.”

“Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved”