The delay in dispatching an ambulance “materially contributed to the premature death” of a Belfast man, an inquest has heard.
Lee Gannon died on February 15, 2022, after his family made four emergency calls for an ambulance after he experienced breathing difficulties at his home in West Belfast.
Despite making numerous emergency calls, the 25-year-old’s condition was not deemed a Category 1 emergency and he did not reach hospital for almost four hours after the initial 999 call.
Delivering her findings at Belfast Laganside Court on September 23, Coroner Maria Dougan said the initial 999 call made by the family shortly after midnight on February 15, 2022, should have been registered as Category 1, but was not, instead being listed as a Category 2.
Category 1 calls are given to immediately life-threatening emergencies, requiring a target response time of eight minutes. Category 2 calls are for serious but not immediately life-threatening emergencies, with a target response time of 18 minutes.
On further emergency calls, Lee’s family described his deteriorating condition, including shortness of breath, hallucinations, and rolling eyes. The coroner said there were two further missed opportunities to re-triage the case by ambulance operators.
It was only after the fourth emergency call that Lee was re-triaged as Category 1, but the coroner said by the time paramedics arrived at 3:43am, it was too late.
Coroner Dougan said: “I find the incorrect categorisation of the initial call and further failures to re-triage resulted in a substantial delay in ambulance attendance and transfer to hospital.
“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.”
Coroner Dougan said this is not the first inquest in recent years where delays in ambulance emergency response times and delays in handing patients over to Emergency Departments featured.
She said: “The evidence before me demonstrated the significant effect which prolonged hospital handover delays can have upon the availability of ambulance resources to respond to patients in the community.”
The coroner said this inquest has highlighted the “critical importance” of accurate call categorisation, especially where information is provided concerning breathing difficulties and deteriorating conditions.
“It has also demonstrated the importance of recognising deterioration during repeat calls and ensuring that updated clinical information is appropriately considered and acted upon,” she added.
The coroner highlighted that the Northern Ireland Ambulance Service was open throughout the inquest, accepting fault and sharing their commitment to learning from Lee’s death.
She acknowledged that since 2022, work had been undertaken in relation to dispatcher training and guidance, and the provision of additional clinical support within the control room.
During evidence given during the inquest by his family, Lee was described as “kind, humorous, much-loved”, as well as a “mummy’s boy” and “beautiful soul.”
Following the conclusion of the inquest in September 2025, Lee’s mum, Anne, passed away. Closing the inquest, Coroner Dougan said: “Throughout these proceedings, her devotion to her son was unmistakable.
“It was of great sadness she did not hear the delivery of these findings, and I wish to put on record my sincere condolences to the wider Gannon family on the loss of Anne and Lee.”
For all the latest news, visit the Belfast Live homepage here and sign up to our daily newsletter.
You must be logged in to post a comment Login