A Scottish man died of cardiac arrest after an ambulance service employee failed to alert a remote paramedic to his condition, an inquiry has found.
Graham Anderson, 59, died in his office at CalaChem Ltd in Grangemouth on May 1, 2020.
A colleague discovered him lying face down following a heart attack, with white eyes and hot to the touch, and called 999 for help just before 8am.
The incident was assessed through a Scottish Ambulance Service triage system introduced during the Covid-19 pandemic.
It was allocated a “teal” code, which meant no ambulance would be sent.
The case was then passed to an advanced paramedic co-ordinator (APC) based in the control room, who allocated the call to the next available remote advanced paramedic (RAP) for further triage.
However, the APC did not follow this up with a telephone call to the RAP, as expected by the triage system.
That meant that the RAP was unaware the case had been allocated to him.
“In effect this stopped all Scottish Ambulance Service management of Mr Anderson’s condition,” Sheriff Keith O’Mahony wrote in his determination.
“No ambulance had been despatched, nor had anyone been tasked with following up additional triage.”
A further 999 call from CalaChem asking what time the ambulance would arrive, along with one from SAS to those with Mr Anderson asking about his condition, also did not prompt any further action from the SAS, the sheriff found.
About an hour after the call had been allocated to an RAP, a control room manager noticed that no action had been taken, and at 9.10am the APC rang the RAP, who went to the scene.
The sheriff said: “From this point Mr Anderson comes back into the view of the SAS.
“Thus, the evidence discloses that for approximately one hour between 0810 and 0910, the Scottish Ambulance Service lost sight of Mr Anderson and did nothing to manage his need for treatment.”
An ambulance arrived at the CalaChem gatehouse at 9.22am.
However, by the time crew arrived at Mr Anderson’s side he was in cardiac arrest.
They took over CPR from CalaChem first responders and a second ambulance crew arrived to help, but Mr Anderson was pronounced dead at 10.21am.
The cause of death was coronary artery atheroma and thrombosis, the inquiry was told.
The inquiry, held at Stirling Sheriff Court in 2024, heard from expert witness Dr Andrew D Flapan, a consultant cardiologist.
He was asked if Mr Anderson had arrived at hospital before his cardiac arrest at around 9.20am, whether he would have been more likely than not to have survived.
Dr Flapan replied that while there was no guarantee, he would like to think so as once in the cardiac laboratory at the hospital, Mr Anderson would have had the clinicians and equipment to treat him, increasing his chances of survival.
Sheriff O’Mahony said the one hour lack of action was “highly significant”.
He found the death might have been avoided had the APC phoned the RAP at the point of allocating Mr Anderson’s case to him, as that would have alerted him to the need to triage Mr Anderson as soon as possible.
The inquiry heard a significant adverse event review was held by the Scottish Ambulance Service following the death which made seven recommendations, all of which have been implemented.
A Scottish Ambulance Service spokesperson said: “This is a tragic case and we would like to apologise again to Mr Anderson’s family.
“An investigation into the circumstances relating to the delay in responding to Mr Anderson was conducted and completed prior to this inquiry, with all actions identified being implemented.
“We would like to extend our deepest sympathies to the family for their loss.”
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