Mark Stephen Smith · Prevention of Future Deaths report

On 28th Day of March 2013 I commenced an investigation into the death of Mark Stephen Smith aged 52 years old. The investigation concluded at the end of the inquest on 16th October 2013 . The conclusion of the inquest was a narrative conclusion Mark Smith having died of Zopiclone and Mirtazapine overdose complicated by ethanol use with chronic obstructive pulmonary disease and coronary artery atheroma under paragraph 2.

On the 2nd March 2013 Mr Smith telephoned for an ambulance having intentionally taken more of his medication than the dose prescribed by his doctors.
There was a delay from 8.57 and 53 seconds, when an ambulance should have reached Mr Smith, to 11.18 and 17 seconds when the ambulance arrived to assist Mr Smith.

This delay was the result of a recognised mismatch between capability and demand and on the 2nd March 2013 between 3am and 2pm there were 15 and 20 ambulances short pan-London. This delay was likely to have contributed to Mr Smith’s death.

Following Mr Smith’s call to the London Ambulance Service the Emergency Medical Dispatcher obtained the correct determinant for the response ,(a response under 30 minutes).

When taking a call from a person threatening suicide and who is alone, as Mr Smith was, the instruction within the operating procedure OP060 is that the fact that the caller is alone should be documented and the person has taken an intentional overdose and is alone, the Emergency Medical Dispatcher should stay on the line with them where possible.

The Emergency Medical Dispatcher did not note that Mr Smith was alone and did not stay on the line with Mr Smith. Had these steps been taken it may have been possible to recognise at an earlier stage when Mr Smith, who, although the Emergency Medical Dispatcher did not know this, had taken medication that would render him unconscious within 30 to 45 minutes. This significance of this would be that had Mr Smith fallen unconscious and the Emergency Medical Dispatcher had known this the call would have been upgraded to a response within 8 minutes.

Consideration to be given to giving guidance on what “where possible” in the terms of the above section of OP060 and whether a supervisor should be consulted before the decision is taken not to stay on the line where a person has taken an intentional overdose and is alone.