On 24th December 2014 commenced an investigation into the death of Ms. Kala Michelle Skinner; age 44 years_ The investigation concluded at the end of the inquest on Gth August 2015 The conclusion of the inquest was that the medical cause of death was I(a) Cardiac failure; I(b) Cardiomyopathy; Il Asthma and the conclusion as to the death was Natural Causes_ However; at Part 3 of the Record of Inquest recorded "The deceased was experiencing breathing difficulties and an ambulance was summoned. Owing to incorrect interpretation of clinical symptoms an inappropriate level of response was assigned to the call: This together with a high level of demand and lack Of resources on the part of the ambulance service meant there was a significant delay before an ambulance attended. As a result the deceased died before she could be taken to hospital"

On 17th December 2014 at 00.00 hours SWASFT received a 999 call via the electronic link from NHS 111 for the deceased who had breathing difficulties NHS 111 had triaged the call for a response within 30 minutes_ There was delay in despatching an ambulance owing to a high level of demand and a welfare call was made at 00.52 hours. At 01.40 hours a Clinical Advisor made contact and following triage retained the same level of response_ The Clinical Advisor had 3 years experience in the role and had previously been an Emergency Care Practitioner. At 01.22 hours an ambulance was despatched but recalled within two minutes and diverted to a higher priority emergency call: A further ambulance was despatched at 02.20 hours and again this ambulance was recalled this time within four minutes and diverted to a higher priority emergency call. At 03;03 hours (three hours after the initial 999 call via NHS 111) a further 999 call was received the deceased s family to advise she had fallen down the stairs and was unresponsive; The call was responded to as an emergency and a Rapid Response Vehicle (RRV) was on scene at 03.15 hours At 03;17 hours a double crewed ambulance (DCA) arrived on scene. The deceased was found to be in cardiac arrest and died at the scene_ According to the level of response initially assigned to the call (Green 2) a welfare call should have been made to the patient carer every 30 minutes if no ambulance was despatched and attended Only one welfare call was made, 52 minutes after thecnitial call; between the initial call at 00.00 hours and 03.03 hours when the second 999 call was made from

The Clinical Advisor who made contact at 01.40 hours missed critical 'red flags' which meant the priority of response should have been increased from an urgent response (green 2) to an emergency response (red 2)_ The deceased was known to be asthmatic and was gasping for breath, taking short breaths was unable to speak in full sentences, all of which were 'red flags' requiring an increased priority of response. Furthermore the deceased was positioned at the top of the stairs and notwithstanding the deceased being in this position and the symptoms the deceased was exhibiting the Clinical Advisor decided that the deceased s daughter, who was with her mother; could go to bed provided she 'kept an ear out' for any deterioration in her mother's condition or the ambulance arriving: In giving such advice the Clinical Advisor did not juard against the risk of deterioration nor ensure the safety of the deceased.