Joseph Michael Miller · Prevention of Future Deaths report

On 6th June 2023 I commenced an investigation into the death of Joseph Michael Miller. The investigation concluded on the 2nd February 2023 and the conclusion was one of narrative: Died from the complications of a seizure contributed to by the use of cocaine. The medical cause of death was 1a) Hypoxic Brain Injury 1b) Cardiac Arrest on the background of a seizure and cocaine use

On the 31st May 2023, Joseph Michael Miller was seen by a neighbour to be fitting in the garden of his home address. A call was made to the ambulance service that was initially categorised as category 1 but downgraded to category 3 when it was reported that he was no longer fitting. A further call was made when he had another seizure and became unconscious. Ambulance crews attended. The initial Rapid Response Team were there within eight minutes. He did not return to consciousness despite extensive efforts to resuscitate him. He was transferred to Tameside General Hospital where tests on the 3rd June confirmed severe hypoxic brain injury and he was declared dead on 5th June.

1. The inquest heard evidence that different ambulance services use different pathways that can impact how calls are categorised /downgraded. The consequence of this is that how the ambulance services across England deal with a call varies depending on where you live. As an example in this inquest, because of where Joseph lived, calls can go to EMAS or NWAS depending on which mobile telephone mast the call pings on. The initial call went to EMAS who on being told he was no longer fitting downgraded the call, in line with their pathway. The inquest was told that had the call been dealt with by NWAS they would not have downgraded the call to a category 3 in this situation because that was not how their pathway operated.

2. The consequence of these different pathways is that there is not a consistent approach to call categorisation across the country which can have a significant impact on the dispatch of potentially lifesaving attendance by the ambulance service.