Man died after calling 999 as ambulance crew failed to find him, inquiry hears

Key Points

David McClenaghan, 57, died after collapsing in a car dealership having dialled 999 for help
The 999 call was disconnected before ambulance staff could confirm his exact location
A dispatched ambulance left shortly after arriving without getting out of their vehicle
A sheriff ruled the crew’s actions were reasonable
The inquiry identified gaps in guidance and technology at the time

A man died after collapsing at work and lying undiscovered for more than an hour after a 999 call was cut off, and ambulance crews were unable to find him, a Fatal Accident Inquiry has heard.

David McClenaghan, a car sales manager from North Lanarkshire, fell ill at Park’s showroom in Coatbridge on August 26, 2018.

The 57-year-old dialled 999 for help at around 5.45pm after collapsing alone in his office. However, the call was disconnected before ambulance staff could confirm his exact location or assess the seriousness of his condition.

An ambulance was dispatched to the site, but when the first crew arrived, they were unable to locate him and left shortly afterwards without getting out of their vehicle.

More than an hour later, a security guard discovered Mr McClenaghan lying behind his office door. Despite efforts to resuscitate him, he was pronounced dead at the scene.

The inquiry heard that Mr McClenaghan died after suffering a cardio-pulmonary arrest caused by a pulmonary thrombo-embolism following a deep vein thrombosis in his right calf.

Failure to exit the vehicle

Sheriff Paul Haran ruled there were no reasonable precautions that could have been taken which would have prevented Mr McClenaghan’s death, and found no defects in any system of work that caused or contributed to it.

However, he said the failure of the first ambulance crew to exit their vehicle when they attended at the garage was “a fact relevant to the circumstances” of the death.

The call from Mr McClenaghan was recorded as an unconfirmed location and categorised as a third-party call, meaning limited information was passed to the responding crew.

The inquiry found there was a lack of clear policy or guidance in place at the time detailing how ambulance crews and dispatch staff should respond when a patient could not be located.

As a result, the first crew carried out a drive-through search of the forecourt but did not attempt to enter any buildings on the site.

The inquiry also heard that the Scottish Ambulance Service’s telephony systems at the time did not allow call handlers to easily distinguish between silent calls and disconnected calls.

Sheriff Haran recommended that the Scottish Ambulance Service explore whether new telephony technology could be introduced to assist call handlers in identifying disconnected calls, and to implement any suitable solution as soon as possible.

The probe heard there had been “significant change and improvement” to procedures since Mr McClenaghan’s death, including the introduction of clear national guidance for dealing with unconfirmed locations and missing patients.

Mr McClenaghan’s wife, Georgina, told the inquiry she only discovered that an ambulance had attended after checking his mobile phone a week after his death.

She said: “I took the phone and discovered there was a 999 call made at 5.45, and I was absolutely sick because at no time had I been told that an ambulance had attended David.

“Had I not discovered that, I don’t think I would ever have been told.”

In closing the inquiry, Sheriff Haran expressed his condolences to Mr McClenaghan’s family, praising the dignity with which they had engaged in the process.

Andy Shanks of the Crown Office and Procurator Fiscal Service, Scotland’s death investigation authority, said: “We note the Sheriff’s Determination and the recommendation made for the Scottish Ambulance Service.

“The Procurator Fiscal ensured that the full facts and circumstances of David McClenaghan’s death were provided at the discretionary Fatal Accident Inquiry.

“The Determination has been provided to the representative of Mr McClenaghan’s family. Our thoughts are with them at this time.”