A CORONER has sent an official report to government and NHS officials warning of possible future deaths should lessons not be learned by the death of a 24-year-old from Penrith.

Lee Armstrong, originally from Carlisle, died on February 2, 2024 in the Cumberland Infirmary from a hypoxic brain injury caused by a medical crisis due to Addison's Disease.

Assistant Coroner for Cumbria, Mr Robert Cohen, raised concerns about the emergency call-handling procedure used by the North West Ambulance Service and devised by NHS England, which meant that on January 30, around six hours passed between the first 999 call made by Mr Armstrong’s partner and an ambulance arriving after a second call.

By this time Mr Armstrong was ‘deeply unconscious and critically unwell’.

Mr Cohen sent the report to the Transformation Directorate of NHS England and the Secretary of State for Health and Social Care.

READ MORE: Coroner calls for NHS changes after death of 24-year-old 'amazing man and father'

He pointed out that Mrs Armstrong’s partner has initially used the 111 service, into which she input his medical history and existing conditions. the result of which was that she should call 999.

The reported highlighted three 'matters for concern'.

Firstly, it said: "The evidence indicates that knowledge that Mr Armstrong suffered from Addison’s Disease would have dramatically altered the response to the call.

"However, the NHS Pathways system does  not  ask  callers  to  indicate  whether  they  have  any  existing conditions. 

"Instead, the  onus  is  placed  on  patients  to  identify  potentially  relevant conditions.

"However, Mr Armstrong had indicated that he was confused.

"I am concerned that expecting a patient to volunteer crucial information about their condition, especially where that condition may cause confusion, places similar patients at risk."

Secondly, it says: "The evidence indicates that information supplied to 111 online is not shared with NWAS, in contrast to information provided to 111 over the phone.

"This may mean that a caller expects that their medical history and condition are known by ambulance call handlers when this is not the case.

"This risks such callers not volunteering details of the medical history."

READ MORE: 'Very unhelpful' NHS Trust criticised by coroner at window cleaner's inquest

Finally, Mr Cohen’s report said: "I note that NWAS call handlers are not provided with access to even an abridged version of a patient's medical records.

"I am concerned that this means that call handlers cannot see relevant details of medical history."

Concluding, he said: "In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action."

Both public bodies must provide a response to the coroner's office by December 24.