A twenty-three-year-old man bled to death after seven calls were made to the ambulance service.
Shiya Jonathan Barnard Collins died on April 29, 2022. Shortly after 10 pm, Mr Collins kicked the glass panel of a door, which subsequently cracked, lacerating the young man's leg.
An ambulance was called for Mr Collins, but his case was not marked with the highest priority, and the ambulance service did not respond quickly enough.
Mr Collins was "suffering significant blood loss and his clinical condition was worsening".
Even though seven further calls were made to the ambulance service, the computer system meant that clinicians were not able to change the category of the call, despite information indicating that an urgent response was necessary.
Now, Senior Coroner for the Newcastle and North Tyneside area, Georgina Nolan, has said that there is a risk that future deaths may occur in similar circumstances if action is not taken.
She noted that seven calls were made to the North East Ambulance Service (NEAS) after the initial call, all of which indicated that Mr Collins' condition was deteriorating rapidly.
During the course of these calls, handlers recognised the need for a clinician to upgrade the ambulance to the highest level.
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Despite this, the locking facility on the Cleric computer system used in the control room precluded any clinician from assessing/upgrading the call because the system was locked and unable to be accessed whilst live calls relating to the case were ongoing.
Coroner Nolan said: "In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action."
The coroner directed his comments to the managing director of Cleric Computer Systems and sent copies of his report to other interested parties, including the North East Ambulance Service
Director of quality and safety at North East Ambulance Service, Julia Young, said: “This is an extremely tragic case, and we send our condolences to Shiya’s family and loved ones.
“We were not able to reach Shiya as quickly as we would have liked and we apologise for the distress this has caused.
“We supplied the coroner with all the information required and we have been working within our emergency operations centre to improve our systems, processes and communication and will act on all recommendations that have been made.”
Cleric is under a duty to respond to the report within 56 days, with details of action taken or proposed to be taken alongside a timetable for this action.
The Northern Echo asked Cleric for a comment, but did not receive a response.
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