A great-grandfather who was coughing up vomit died after NHS 111 service call handlers repeatedly failed to send him an ambulance, an inquest heard.
Harry Gill died 20 minutes after an ambulance sent to the 72-year-old’s home on Riding Barn Street, Church, was cancelled en-route.
An inquest heard that his family had called the 111 service after he began 'coughing up vomit’.
NHS bosses have apologised after the hearing was told that the calls were ‘incorrectly processed’ by staff and on three occasions an ambulance should have been sent within 20 minutes.
After the hearing, Harry’s stepson Peter Eastwood called for an ‘in-depth review’ into the case. He said: “[Harry] was never as proud as when he got a job as a porter on the NHS in 1977 and then as a mortician.
“It’s a shame really that the service he fought for and supported and loved has let him down at the end.”
Coroner Michael Singleton concluded that the 111 service ‘failed to respond appropriately’.
He said he will now consider issuing a report to the service to try and prevent any similar future deaths.
An inquest at Blackburn Coroners Court heard how call handlers advisers had ‘appallingly handled’ four calls from Mr Gill and his wife Dianne over a two-day period and on three occasions had failed to conclude that an ambulance should be dispatched to him.
A post-mortem examination by Dr Richard Prescott found that Mr Gill’s bowel had become incarcerated in hernias on both sides of his groin and was ‘intermittently obstructed’, which caused his vomiting.
The inquest heard how Mr Gill had a ‘failing heart’ and his repeated vomiting and loss of fluid and electrolyte imbalance ‘placed on a strain’ on his heart and led to a fatal heart attack.
Mrs Gill told the inquest how her husband had been ‘fit and well’ until they attended a wedding reception on May 28, when he started feeling sick.
She said the next day his vomit had turned into a ‘brown substance’’.
The hearing was told that four out of the five calls made between Mr and Mrs Gill and the NHS 111 service were ‘incorrectly processed’ by the call handlers and on three occasions a ‘green 2’ code ambulance should have been sent within 20 minutes.
When questioned about the calls, NHS 111 clinical quality and nurse lead Alison Neville-Ralph agreed that they had been ‘appallingly handled’.
Mrs Gill contacted the NHS 111 service on June 1 and again on June 2, however on both occasions the call handlers ‘incorrectly processed’ the call.
The inquest heard how the service uses the NHS Pathways clinical assessment tool for triage calls from the public based on symptoms they report.
Coroner Michael Singleton recorded a narrative verdict but ruled that the ‘111 service failed to respond appropriately such that medical treatment was not made available to him’.
Addressing Mrs Gill he said: “You sought medical help and medical advice and it’s a tragedy that was not forthcoming in the way that clearly it should have been.
“It’s important that if you are going to have a triage system then the system must be able to drill down and find out those that almost overstate their illness as well as those who understate.”
NHS bosses apologise for errors
Health bosses have apologised for the errors leading to Harry Gill’s death and said new procedures and extra training have been put in place to prevent it happening again.
Alison Neville-Relph, NHS 111 clinical quality and nurse lead, said the service handles up to two million calls every year and that Mr Gill’s case was an ‘unfortunate and isolated incident’.
Ms Neville-Relph said four out of the five calls made between Mr and Mrs Gill and the NHS 111 service were ‘incorrectly processed’ by the call handlers and on three occasions a ‘green 2’ code ambulance should have been sent within 20 minutes.
She told the inquest: “All of those individuals have gone through action plans and further training and development and every single one of those individuals, upon reflection and listening to the calls, have identified the errors that they made.
"We have an ongoing culture where coaching and audit feedback are a very high priority. I’m deeply personally sorry for this occurring.”
The inquest heard how the four staff were ‘taken off-line while reflection and targeted action plans were put in place’ and that changes have been requested to the ‘misleading’ NHS Pathways vomiting and nausea questions relating to blood or faeces.
‘He was let down by service he loved and fought for’ say family
The family of former NHS porter Harry Gill said he loved the health service and it ‘let him down when he needed it the most’.
His stepson Peter Eastwood has blasted the ‘stack of errors’ which led to his step-father’s death and called for an ‘in depth review’ into the case.
After the inquest, he said: “We need to make sure that no other family goes through what’s happened to us.
“It seems to have been a stack of errors.
“What’s happened within the service really should be taken away and addressed at a more in depth review.
“He was a child of the health service.
“His dad was in the RAF in India as a male nurse. Harry was always keen on medicine because of his dad and was never as proud as when he got a job as a porter on the NHS in 1977 and then as a mortician.
"It’s a shame really that the service he fought for and supported and loved has let him down at the end.”
Dianne Gill said: “The tragic outcome of this is that my husband has been denied living longer into his retirement.
“I just don’t want anyone else to go through what I’ve gone through.
“He was a true gentleman. He was liked by a lot of people and will be missed by a lot of people.”