Boy who died from asthma attack could have survived, coroner rules

Schoolboy, 15, who died from asthma attack after 999 call was downgraded by computer algorithm could have survived if he received medical attention sooner, coroner rules

  • Martin Sullivan died in November 2019 at Tameside Hospital after asthma attack 
  • Coroner concluded death could ‘possibly’ been avoided with medical attention 
  • Family’s 999 call was graded ‘Category 2’ rather than most urgent ‘Category 1’

A schoolboy who died from an asthma attack after his family’s 999 call was downgraded by a computer algorithm could ‘possibly’ have survived if he had received medical attention sooner, an inquest heard.   

Martin Sullivan, a talented musician from Ashton-under-Lyne, Greater Manchester, died at Tameside General Hospital after fighting for breath in November 2019.

The 15-year-old, who had been to hospital twice following asthma attacks in 2015 and 2016, took regular medication but his parents believed his condition was well managed and under control.

An inquest into Martin’s death concluded at Stockport Coroner’s Court yesterday.  

Coroner Andrew Bridgman recorded that Martin died of natural causes but said that his death could have ‘possibly’ been avoided if he had received medical attention sooner.

Martin Sullivan, a talented musician from Ashton-under-Lyne, Greater Manchester, died in November 2019 at Tameside Hospital after fighting for breath in an asthma attack. Pictured: Martin with his sister Rebecca

He said that the ‘opportunity for him to receive medical attention was denied’ because the call handler did not suggest that his father take Martin to the hospital himself. 

Instead, Roy Sullivan was ‘left with an agonising wait for an ambulance that was unlikely to attend’, the coroner said. 

Mr Sullivan phoned the emergency services at around 6.10am on November 24 and asked for an ambulance, telling the call handler his son was having an asthma attack. 

When he was asked if his son was still conscious and breathing, Mr Sullivan had to give the technically correct answer ‘yes’, but he stressed that Martin was struggling for air. 

The answers were fed into a computer, and Martin’s plight was graded ‘Category 2’ instead of the most urgent ‘Category 1’ response, reserved for immediate life-threatening emergencies.

After paramedics failed to show up at the family home promptly, Mr Sullivan decided to make the 10 minute journey to hospital himself with his son in the passenger seat.

The 15-year-old, who had been to hospital twice following asthma attacks in 2015 and 2016, took regular medication but his parents believed his condition was well managed and under control. Pictured: Martin

Coroner Andrew Bridgman recorded that Martin died of natural causes but said that his death could have ‘possibly’ been avoided if he had received medical attention sooner. Pictured: Martin

The schoolboy was rushed into A&E but passed away two hours later in Tameside Hospital despite attempts to revive him.   

Mr Bridgman said: ‘I’m sure that if he had been told on calls that the service was busy and that he could take him to hospital himself, then he would have done’.

During the inquest, which began on Monday, Mr Sullivan said in a statement that he believed his son’s life might have been saved had an ambulance been sent to help sooner.

An ambulance arrived at the family home at around 7.10am that morning, around 54 minutes after the first call was made.

But Mr Sullivan said it was ‘clearly much too late to be of any help’.

Expert witness Dr Mark Levy told the inquest that there was a ‘possibility that Martin would have survived had he received medical attention at or around 6.30am’.

A member of staff from NWAS paid the family a visit after Martin’s death, and explained that a crew had been tied up at a job in Stockport.

‘I did not feel that the paramedic understood the gravity of what happened to our family after losing our beloved son,’ Mr Sullivan added in his statement.

The family subsequently learned that their request for an ambulance had been logged as Category 2 during both calls.

At that time, there were 39 unallocated Category 2 calls across the service. The inquest heard that Category 1 responses were reserved for immediate life-threatening emergencies.

‘Had he been assigned a Category 1 response, I wonder whether Martin would still be alive,’ said Mr Sullivan.

While the family agreed with the recommendations of a review carried out by NWAS into Martin’s death, they believe the report did not go far enough.

Coroner Andrew Bridgman asked NWAS bosses whether ambulances had been ‘stacked up’ at A&Es on the morning of Martin’s death.

Daniel Smith, interim head of service for Greater Manchester at NWAS, said: ‘There were some delays.

‘The overall ambulance turn-around for hospitals [in Greater Manchester] was 35 minutes, which is five minutes over the desired time.

Pictured: Martin Sullivan, who died following an asthma attack

‘It was November and we were experiencing turn around delays at a number of hospital sites just because of the pressures on the hospital system at that time.’

Recording a conclusion of death by natural causes, coroner Mr Bridgman said: ‘Martin’s death could possibly have been averted had he received medical attention’.

He suggested that the call handler should have advised Mr Sullivan to take Martin to hospital himself ‘probably on the first 999 call and certainly on the second 999 call’.

The coroner will now write a report to the Medical Priority Dispatch System (MPDS) in relation to the algorithms and scripts used on 999 calls.

He will not write a report to NWAS but recommends that the service maintains a strategy that has already been implemented.

Following the conclusion, Mr Sullivan said: ‘I am very happy with the results of the inquest and know that Martin will now rest a little easier.’

Martin, who was in Year 11 at Great Academy Ashton, was described during the inquest as a clever, helpful youngster who had grown up in a tight-knit family.

His teachers said he was a ‘passionate, motivated and helpful’ pupil who had loved music and been active on the school council and local youth parliament.

Paying tribute, his sister Rebecca said in statement: ‘Our mum still washes clothes for him and cooks meals for him everyday hoping he will come home.

‘Martin brought so much joy to our family. We will never be the same without him.’ 

Ged Blezard, Director of Operations at NWAS, said: ‘Our deepest sympathies remain with Martin Sullivan’s family in what remains an incredibly difficult time for them.

‘We acknowledge the coroner’s findings and thank him for his handling of what is a very sensitive case.

‘It was recognised that the two 999 calls we received from Mr Sullivan were coded correctly in line with national standards but we welcome and will fully comply with any changes to those standards that may occur as result of the coroner’s recommendations, in the hope that a further tragedy can be avoided.’

‘In the last year we have increased the number of ambulances and front line staff aimed at improving response times to all categories of incident.’

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