The coroner, Marie Dougan, said the initial 999 call made by the family should have been registered as a Category 1 – reserved for immediately life-threatening medical conditions – but it was not.
There were two further missed opportunities to reassess and re-triage the case by ambulance operators when the family described Lee’s deteriorating condition.
After the fourth 999 call Lee was re-triaged as Category 1, but the coroner said by the time the paramedics arrived it was too late.
“I find that the incorrect categorisation of the initial 999 call and the subsequent failures to re-triage the deceased resulted in a substantial delay in ambulance attendance and transfer to hospital,” the coroner said.
“That delay deprived the deceased of timely and appropriate assessment and treatment at the Royal Victoria Hospital for pneumonia and sepsis and materially contributed to his premature death.”
Delivering her findings, Dougan added this was not the first inquest where delays in ambulance response times featured and prolonged delays in handing over patients to Emergency Departments remained a problem across Northern Ireland.
“The evidence before me demonstrated the significant effect which prolonged hospital handover delays can have upon the availability of ambulance resources to respond to patient in the community,” Dougan said.
She acknowledged that the Northern Ireland Ambulance Service (NIAS) was open throughout the inquest, had accepted fault and were committed to learning from his death.
The court heard how Lee’s mother Anne was devoted to her son and that he was known kindly as a mummy’s boy who loved living in the family home.
Dougan said while it was Anne’s desire to understand what had happened to her son that night, it was a matter of great sadness that she hadn’t survived to hear the findings.
