Terence Norbert Dooley · Prevention of Future Deaths report

On the 7th January 2014 I commenced an investigation into the death of Terence Norbert Dooley, aged 45 years. The investigation concluded at the end of the inquest on the 7th January 2014.

The cause of death was found to be:

1a Ingestion of excessive amounts of Citalopram, Mirtazapine and Propanolol

The conclusion of the inquest was as follows:
Narrative conclusion: Terence Norbert Dooley was found deceased on 29th October 2013, having taken a fatal dose of medication. Due to a heavy demand on the Ambulance Service, attendance to him was delayed by 2 hours 38 minutes.

Mr Dooley had taken an overdose of tablets and he telephoned 999 for an ambulance, informing the call handler that he had taken a mixture of 40 tablets. He complained of feeling hot and said that he could not feel his legs. He gave his location as being on a bench next to Butler Bridge by the canal. He was able to name the tablets he had taken and was informed that a response car would be with him in 20 minutes. However, it was 2 hours 38 minutes later when a response vehicle was dispatched. By the time the response vehicle arrived Mr Dooley had wandered off. On the evidence heard in court, he most likely entered the water to cool down. He was found on the bank by the canal, wet with wrinkled skin and unresponsive at 0800hrs. He had called the service at 0151hrs.

1. Despite the fact that each different tablet could be fatal on its own, let alone together, this call was given a code green.
2. This was an emergency and a delay of 2 hours and 38 minutes is totally unacceptable regardless of pressures on the service due to Halloween.
3. There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes.
4. The computer generated codes are misleading. One dash is one too many when it should have, and could have been avoided.