Sarah Gilbert-Jones

“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.”

“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.”

“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.”