A coroner has ruled that the death of a 25-year-old Belfast man from pneumonia in February 2022 was preventable, after the initial 999 call was incorrectly categorised as a Category 2 rather than Category 1 emergency.

Lee Gannon, from the Beechmount area, died at the Royal Victoria Hospital on 15 February 2022 from right-sided lobar pneumonia and sepsis. He had been ill for several days and his family made the first of four 999 calls to the Northern Ireland Ambulance Service (NIAS) at 00:19 that morning.

Coroner Maria Dougan found that the information provided during that first call, including that Mr Gannon was “barely breathing” and talking “gibberish”, should have led to a Category 1 response, which has an eight-minute target. Instead, the call was categorised as Category 2, with an 18-minute target. An ambulance did not arrive until 03:43, more than three hours later, by which time Mr Gannon was in cardiac arrest.

During the inquest, emergency medical dispatcher Zena Gardener accepted that the call should have been Category 1, agreeing that the description of “barely breathing” indicated ineffective breathing, which should have triggered a different protocol. The coroner also found that Mr Gannon’s alertness was incorrectly recorded: his mother’s responses suggested he was not fully alert, but this was not reflected in the triage.

Subsequent calls at 00:31 and 02:01, during which Mr Gannon’s family reported worsening symptoms including hallucinations, inability to speak and rolling eyes, should have prompted new triage assessments, but did not. Dispatchers Andrea Hunter and Clare Mercer both accepted they should have re-triaged the calls.

The coroner found that the incorrect categorisation led to a substantial delay in ambulance attendance. Expert evidence from respiratory consultant Dr Mohammad Al-Aloul indicated that had a Category 1 response been made to the first call, Mr Gannon would likely have arrived at hospital by around 01:00, almost three hours before he stopped breathing. Dr Al-Aloul said it was “probable” Mr Gannon would have survived with a timely Category 1 or even Category 2 response to the first or second calls. However, by the fourth call at 03:26, the window for survival had passed.

NIAS chief paramedic Neil Sinclair apologised during the inquest, stating the response “fell below the standards we strive to achieve”. The service accepted the findings of its own Serious Adverse Incident review, which identified missed opportunities in the control room. NIAS has since introduced enhanced training on ineffective breathing, strengthened auditing, and expanded clinical support in the control room.

The coroner also noted that ambulance availability was severely affected by delayed hospital handovers, but found those pressures did not cause the incorrect categorisation. She stressed the importance of accurate call triage and recognising deterioration during repeat calls, and expressed hope the findings would contribute to improved patient safety.

After the inquest concluded, the coroner was informed of the death of Mr Gannon’s mother, Anne Gannon, who had pursued the circumstances of her son’s death with “determination and dignity”.