Paramedics attending an urgent 999 call after a man took his own life on Christmas Day were initially sent to the wrong address, an inquest heard.

An ambulance crew turned up at Osborne Terrace in the Leeholme area of Bishop Auckland when it should have been sent to Osborne Terrace in Evenwood.

Details of the delay emerged at the inquest into the death of 36-year-old Christopher Martin at Crook Coroners’ Court on Wednesday.

The court heard Mr Martin was found hanged at his home on December 25 and the call was made at 10.17pm.

Craig Fox, a duty officer with North East Ambulance Service, who investigated the response said the address in Leeholme was taken by the NEAS call handler and the postcode was confirmed by the control room at Durham Constabulary.

He said: “At 10.25pm it is heard on the call someone in the background saying it is Evenwood, not Leeholme.

“From that point on the advisor tried to ascertain the correct address.

“At 10.27pm they are advised by the homeowner it is not this address.

“They contacted control and are advised to travel to Evenwood.”

Ambulance crews did not arrive until 10.39pm – 22 minutes after the initial call was made.

It was categorised as a high priority but the health advisor initially logged that Mr Martin was breathing which was incorrect.

When the first paramedic, Sean Storey, arrived, two police officers were doing chest compressions and trying to help Mr Martin breathe using a pocket mask.

Mr Storey has conceded in hindsight he could have given supplementary oxygen but Mr Fox points out this would have meant no-one was then available to provide more complex treatment or administer drugs.

He said: “It is true that errors did occur and treatment was not optimal treatment. There was a delay in providing supplementary oxygen.

“It was a very difficult situation for the clinician that attended the incident.

“He has made a judgement call based on what he saw.

“He decided that the best thing for Mr Martin was to move on to the more advanced procedures.

“If he had taken over the airway management it means he cannot do anything else because there is no-one else in the room who can do advanced procedures, so then there would have been delays in giving him drugs which could then have had an effect on the outcome.”   

Mr Martin, who was unemployed at the time, was taken to Darlington Memorial Hospital, but was pronounced dead in the early hours of Boxing Day.

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In his report, Dr James Limb, consultant in anaesthesia and intensive care, said the delays would not have had any effect on the clinical outcome for Mr Martin who had developed brain hypoxia.

A post-mortem examination confirmed the cause of death was hanging.

The inquest heard a statement from Mr Martin’s brother, Sean, who said he had been struggling with his mental health.

He said: “Chrissy and I were not just brothers. We were best friends, two peas in a pod.

“He was struggling with his mental health for a while. He had been in a dark place.”

Senior assistant coroner Crispin Oliver ruled Mr Martin’s death was suicide.

He said: “I have been concerned throughout this investigation that mistakes were made by emergency services that created a situation where there was an element of professional breakdown that entered the chain of causation.

“The investigation has thus far established that not to be the case.

“There have been mistakes that have been recognised and the way to deal with them is by training and I am told that is what is happening.”

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