David Anthony SWEENEY · Prevention of Future Deaths report

On 30 April 2015, I commenced an investigation into the death of David Sweeney, aged 28 years. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest as follows.

“David Sweeney’s death was alcohol related.
An opportunity for earlier medical intervention – which might have saved him on this occasion – was lost when a call to the ambulance service was not categorised as a priority.”

The medical cause of death was:

1a hypoxic brain injury
1b acute alcohol toxicity

A member of the public called London Ambulance Service at 4.47pm on 18 April 2015, to report that he could see a man [Mr Sweeney] lying on the ground vomiting. The caller said that the man had been unconscious. In response to the LAS emergency medical dispatcher’s question asking if he was now a little bit awake, the caller replied yes.

The EMD then incorrectly selected the protocol for a sick person instead of the protocol for an unconscious person, and so the call did not receive a categorisation of red 2, target arrival time of 8 minutes, which it otherwise would have done.

Instead, a clinical adviser rang back, categorised it as a C1, and an ambulance arrived 1 hour 40 minutes after the original call, prompted then by a call from the Metropolitan Police Service who had come upon Mr Sweeney.

Just a few minutes before LAS arrived, Mr Sweeney suffered a cardiac arrest and consequent hypoxic brain injury, from which he died a week later.

One of the intensive care consultants who looked after Mr Sweeney in the following days, gave evidence that if Mr Sweeney had been in hospital at the time of his cardiac arrest, he probably would have survived.

A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation.

You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious.

I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients.