Ambulance bosses change procedures after man’s death
- Credit: Archant
Ambulance bosses say they have changed procedures following the death of a man who hanged himself as police waited unsure whether to act because they had been given the wrong name.
Suffolk coroner Jacqueline Devonish had called for East of England Ambulance Service NHS Trust (EEAS) to take action following the death of Mark Harris at the home of his former partner in Bury St Edmunds.
Mr Harris, aged 24, who had a history of suicide attempts, was found hanged at the flat in College Mews on January 11, 2016.
His ex-partner Laura Manning had called the police after Mr Harris texted her saying he was going to kill himself.
But in her Report to Prevent Future Deaths to EEAS interim chief executive Dorothy Hossein and managers at its operations centre in Norwich, the coroner said she was concerned the police were given a mis-spelled version of Mr Harris surname by the ambulance control room.
"Had the correct spelling of the name been provided to the police they would have known Mark Harris and his history of suicide attempts," the report said.
"This was a significant problem for an intelligence-led service."
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A spokesman for EEAS said it had responded to the coroner's findings by issuing new guidelines.
A spokesman said: "The Trust again wishes to express its sympathy to Mr Harris's family.
"We have responded to the coroner's findings by providing Ambulance Operations Centre staff with new guidelines on what information they should provide to police when seeking their attendance.
"We have also added additional questions to existing protocols that call handlers use when police attendance is required.
"The Trust is also involved in several trials with Suffolk and Norfolk police around how we work together and communicate with each other.
"We plan to roll that work out across the six counties once we have assessed its impact."
An inquest jury at Suffolk Coroners Court in Ipswich in January this year concluded Mr Harris's death was as a result of misadventure. They said he had hanged himself but did not intend to die.
The jury identified failures in communication between the ambulance service and police that contributed to his death.
The inquest heard Ms Manning called police at around 1.40pm on the day he died asking for the ambulance service to conduct a welfare check.
She told them he had sent her text messages telling her he was going to take his own life and that they had her permission to force entry.
But despite a police officer and PCSO being sent at 2.20pm, as well as two ambulances being dispatched but diverted to other incidents, his body was not discovered until 5.20pm - three and a half hours after the initial call.
The report also said the officers police were unclear whether they were there to protect ambulance personnel or to perform a welfare check on an individual.
The police told the inquest that had they known it was a welfare call, and given Mr Harris's history, they would have forced entry into the property in the absence of the ambulance service.