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Marie Dougan, the coroner, revealed that the initial emergency call made by the family should have been categorized as Category 1—a classification reserved for immediately life-threatening medical emergencies—but it was not correctly registered as such. Despite the family reporting Lee’s worsening condition, ambulance operators missed two additional chances to reassess and upgrade the urgency of the situation.
It was only following the fourth emergency call that Lee was finally reclassified as Category 1. However, by the time paramedics arrived at the scene, it was already too late. The coroner stated, “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.” This delay meant that Lee did not receive timely assessment and treatment at the Royal Victoria Hospital for pneumonia and sepsis, factors that significantly contributed to his premature death.
During her findings, Dougan highlighted that delays in ambulance response times had been a recurring issue in previous inquests. She also pointed out that prolonged patient handover times at hospital emergency departments continued to negatively impact ambulance service availability 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,” she explained.
The coroner noted that the Northern Ireland Ambulance Service (NIAS) was fully cooperative during the inquest, acknowledged responsibility, and expressed a commitment to learning from the incident. The court also heard about Lee’s close relationship with his mother, Anne, who was described as devoted and lovingly referred to him as a “mummy’s boy.” Dougan expressed sorrow that Anne, though eager to understand what had transpired that night, did not live to hear the coroner’s conclusions
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