A CORONER has said he is 'deeply concerned' after a 24-year-old dad who suffered from a rare autoimmune disease died in hospital after being advised by a 999 call-handler to call his GP hours before collapsing at home.

Lee Armstrong, who was living in Penrith, died at the Cumberland Infirmary in Carlisle on February 2, 2024, three days after being rushed to hospital following a second 999 call made by his partner, Sally, that day.

Paramedics arrived at 4.51pm on January 30, just three minutes after the second call was received, and took Mr Armstrong to Carlisle.

According to Dr Madeleine Wood, an intensive care consultant in Carlisle who took over his care the following day, Mr Armstrong suffered a cardiac arrest in hospital at 6.20pm on January 30.

He could not be resuscitated for around an hour, by which time his brain had suffered 'devastating injury' due to a lack of oxygen.

Mr Armstrong, who suffered from Addison's disease, deteriorated over the next two days, and using brain stem tests, doctors pronounced him deceased on February 2.

According to a statement submitted to Cockermouth Coroner's Court by his mother Debbie, Mr Armstrong had symptoms of vomiting and diarrhoea on the evening of January 28. 

Sally had used the NHS 111 online service at around 10.30am on the morning of January 30, entering Mr Armstrong's symptoms and medical conditions.

She was advised by the service to dial 999.

A transcript of this call was read to the court, during which the call-handler is heard to ask a series of questions to Sally and then to Mr Armstrong.

Assistant coroner for Cumbria, Robert Cohen, quizzed North West Ambulance Service (NWAS) clinical delivery manager Luke Simmonds about the questioning process.

The handler asked Mr Armstrong if his symptoms were preventing him going about all aspects of his daily life, to which he replied ‘yes’.

They then repeated the question, asking if Mr Armstrong could make himself a drink if needed, to which he replied, 'I could if I needed to'.

Mr Simmonds conceded that if the handler had received a clear answer, which they had, they should have moved to the next question in the process.

He said that because they asked again, and received a different answer, a different branch of questioning was followed.

Mr Simmonds said that if the original answer was accepted, paramedics would have arrived within two hours at most, rather than Mr Armstrong being advised to call his GP.

The handler also asked Mr Armstrong if he was more confused than normal, to which he replied 'yes'.

Answering Mr Cohen's questions, he said that the call-handler would not have had any access to Mr Armstrong's medical history, or the details Sally had entered into the 111 service.

He revealed that the 111 online service is national, but if a 111 phonecall was made, it was possible that the information would have been passed on.

He also said that call-handlers are not trained clinically, nor to ask about existing medical conditions, and that they use the NHS Pathways questioning system, which is 'symptom-based' rather than condition-based.

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Though Mr Armstrong's condition of Addison's disease was input into the 111 online system by Sally, it was not mentioned or queried by the handler in the subsequent 999 call.

Mr Simmons said that if it had, an ambulance would have arrived within 40 minutes at most.

Sally called 999 again at 4.48pm after Mr Armstrong had fallen backwards and was unconscious.

Mr Cohen said that at this point, Mr Armstrong was 'in the midst of an Addisonian crisis'.

A GP report said that Mr Armstrong had been treated successfully in the past after experiencing similar episodes.

Mr Armstrong’s mother said in a letter to the court: "We're certain that if an ambulance had been sent following the first call the outcome would've been totally different from the situation we now find ourselves in.

"Awareness needs to be raised so that everybody who deals with these kind of calls know that an ambulance should attend immediately.

"Hopefully some good can come out of this terrible situation by raising awareness towards NWAS personnel."

She also paid tribute to her son, who grew up in Carlisle and attended Caldew School, calling him a 'gentle giant', who had recently become a dad to one-year old Louis.

She said: "He was a lovely child and he turned into a lovely young man.

"He was the proudest dad and wasn't afraid to get stuck in at all with the daddy duties.

"He got involved as much as he could with Louis, and he absolutely doted on him, and it made his family very proud of him to see the amazing man and father that he turned into."

"He was always very funny and had an amazing character."

"More than 200 people came to his funeral."

Mr Cohen accepted the cause of death offered as hypoxic ischaemic encephalopathy, caused by a cardiac arrest and Addisonian crisis, with a contributing factor of type-1 diabetes.

He said that he would be sending a prevention of future deaths report containing three areas of concern to both the transformation director of NHS England, which sets the question and processes of the NHS Pathways system used by 999 call handlers nationwide, and to the Secretary of State for Health and Social Care.

Firstly, that the evidence from this inquest indicated that if the call handler had known that Mr Armstrong suffered from Addison’s disease, the emergency would have been escalated appropriately, and that expecting a patient to volunteer that information is a 'risk'.

Secondly, that 111 online information is not available to the call handler when information provided on a 111 call would be.

Thirdly, he said: "I note that NWAS call handlers are not provided with access to even an abridged version of patient medical records."

He said that the two recipients would have the power to act on these issues.

Mr Cohen paid tribute to an action taken by Mr Armstrong's parents, Debbie and Mark.

He said: "Courageously, Lee's family opted to allow him to become an organ donor, and I'll take this opportunity to say how desperately important it is that people feel able to do that, and to say to Lee's family that out of this tragedy, other people were given the opportunity to live."

In June, the mother of a seven-year-old girl from Merseyside who received a life-saving liver transplant thanks to him, paid tribute to Mr Armstrong, saying his decision had saved four lives.

His family has also set up a charitable initiative to raise awareness of the issues highlighted in the inquest.

Debbie said: "In memory of Lee and to ensure that other people don't meet the same fate, we've created a charitable initiative called Lee's Light.

"It's under Lee's Light on social media - Instagram, Facebook and Tiktok.

"The goal of the initiative is to 'Shine a light' on Addison's disease, raising public awareness of the condition as well as funds for Addison's Disease research, and lastly to advocate for improvements to the NHS to ensure that people with Addison's Disease get adequate care from emergency services.

"My son, Christopher Armstrong is climbing Kilimanjaro in January, which is the first activity we're doing under Lee's Light.

"We're raising funds and creating social media content of the journey, everyone is invited to follow along and hopefully donate to support us in achieving the mission of Lee's Light."