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Inquest: Dying Phillip Marshall was ‘written off’ by NHS call centre

The ex-wife of a man who died in agony after calling the out-of-hours 111 number for medical help told an inquest that response staff “just wrote him off”.

Phillip Marshall, 62, was found at his home in Rainham more than 24 hours after calling the SECAmb-run service complaining of sudden severe chest pains.

A switchboard health advisor referred his case to Medocc, which deals with urgent medical problems when GP surgeries are closed, with the instruction to call him within an hour.

Phillip Marshall, 62, died in agony after calling the out-of-hours NHS number
Phillip Marshall, 62, died in agony after calling the out-of-hours NHS number

After three unsuccessful attempts to reach him on his mobile, the Medocc boss, Dr Simon Collins decided to “close the case” less than three hours after receiving the email from 111.

Medical director Dr Collins told the hearing at Archbishop’s Palace on Monday that it was assumed Mr Marshall was not alone and it was not uncommon for patients to not respond.

He said he also took his age into account thinking if he were 92 he may have been more concerned.

Mr Marshall, who was pronounced dead at the scene, died from bronchial pneumonia.

The hearing was told that Mr Marshall first had an eight minute conversation with 111 operator at 7.43pm on Friday, February 10 this year, in which he complained about pain across the top of his body.

It was picked up by Medocc at 7.50pm and staff called for the first time an hour later.

Further attempts were made at 9.14pm, 9.55pm and then 10.15pm, Dr Collins made final check call at 10.44pm to make sure the number was correct and also made enquiries with the A&E department and SECAmb before halting involvement.

The sequence of events that evening led to a Serious Incident Report which was presented to the coroner’s court.

The inquest was at Archbishop's Palace in Maidstone
The inquest was at Archbishop's Palace in Maidstone

Former wife Sharon Marshall, representing the family, said: “I don’t feel the correct procedures have been followed.

"Personally I feel there have been failings by both parties, 111 and Medocc.

Mrs Marshall, added that the words “sudden chest pains” should have rang alarm bells which should have prompted an emergency ambulance to be dispatched to his home in Middleton Close.

Mr Marshall’s son Dan, 27 discovered his father at about 8.20pm on Saturday, February 11.

He had gone to his home after being worried about not getting hold of him during the day and saw him collapsed in the living room.

Paramedics said the death had “not just happened” and police found a mobile with missed calls from Medocc.

Mrs Marshall, said: “I would not want another family to go through what we have been through.”

Assistant coroner Katrina Hepburn retired to consider issues raised and will announce her outcome at a further hearing on Monday next week.

"I would not want another family to go through what we have been through" - Sharon Marshall

Mr John O’Sullivan, representing SECAmb said it was the health advisers’s job to assess and advise with professional back-up from a nurse and paramedic.

Having listened to the taped conversation, Mr O’Sullivan said: “This gentleman was obviously seriously ill. It didn’t seem to be an emergency situation at that time.”

He said he did not appear to be distressed and answered questions fully. He did not seem to be out of breath or wheezing.

He said: “His condition must have deteriorated very quickly, certainly within 60 minutes.”

He added if an ambulance had been called he could not say it would have arrived in time.

The audit report was critical of the health adviser’s interviewing technique saying she asked two questions in one.

Mr O’Sullivan said she should have “stuck to the script” set out by the NHS Pathways triage system.

Assistant Coroner Katrina Hepburn also raised the matter of if a double question had been posed separately, it may have triggered an ambulance being called.

Mr O’Sullivan described the auditor’s report as “quite harsh and challenging”.

He said he had since met Medocc representatives and they had agreed that the words “HOME ALONE” should be included in future medical reports.

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