On the 11 May 2017 I commenced an investigation into the death of David Michael Lee. I concluded this inquest on 21 June 2017 and found that there was a missed opportunity to escalate the deceased’s call to 999 by NWAS. I also found that NWAS should not have terminated the deceased’s call because in between the call ending and the ambulance attending at the deceased’s home address the deceased became unconscious and died.

The deceased was found unresponsive at his home address on 18 February 2017 and fact of death was confirmed by paramedics when they arrived. An ambulance was called by the deceased at 6 am but did not arrive at the deceased’s address until 7:23 am. The deceased’s call with 999 was terminated by NWAS approximately 30 minutes into the call to enable to call handler to attend to other calls. However, after the call ended the deceased became unconscious and life was extinct prior to the arrival of NWAS. In terminating the call there was a missed opportunity to escalate the response that the deceased req umired. The deceased died from the consequences of diphenhydramine toxicity and had taken a considerable quantity of this drug just prior to death. He made this known to NWAS during his 999 call and the NWAS call handler was aware that the deceased was alone and that he, therefore, would not be able to call back if he became unresponsive and if his condition worsened, which subsequently happened.