Norfolk coroner in future deaths warning after man's inquest

Aran Bradbury died in August last year at the age of 34, having taken an act to end his own life.

He was found unresponsive at his home in Great Melton after paramedics were sent there following a call made by a worker from drug and alcohol services Change Grow Live with concerns about his welfare.

During an inquest into his death, the prioritisation of this call was put under scrutiny, with Mr Bradbury's history of mental ill health limiting how the call was categorised.

Stock image of a 999 call handler (Image: Archant © 2013) This, in turn, resulted in the call being given a lower priority and therefore a slower target response time for an ambulance.

The case prompted assistant coroner Christopher Leach to publish a prevention of future deaths report citing his fears about the way calls relating to mental health are prioritised.

The court heard evidence that 999 call handlers are given a series of questions and prompts to ask callers, which in turn digitally generates the call priority.

When evidence is given of mental health conditions, the automated system limits priority to category 3, unless certain other conditions are made - with a target response time of two hours.

Had Mr Bradbury's history of mental ill health not been factored in, it is likely he would have been classified as a category 2 call - with a target response time of 18 minutes.

This was due to a suspicion he had taken illicit substance and was prone to overdosing.

And while it is not clear whether a faster response would have made a difference to Mr Bradbury - who suffered a hypoxic brain injury in the incident and died in hospital four days later - the coroner warned of the system's flaw.

In his report, Mr Leach wrote: "The operation of this system could result in patients who might otherwise warrant a category 2 prioritisation being prioritised as category 3 and therefore wait longer for an ambulance to attend.

"Patients with a history of mental illness would appear to fall within this group."

Mother welcomes report

Aran Bradbury, who died at the age of 34 (Image: Much Loved) Amanda Bradbury, Mr Bradbury's mother, welcomed the coroner's report, echoing his fears about the system.

She said: "Throughout Aran's life and situation, I was always made to feel like he didn't matter.

"As a family, we tried so hard to get him help but there was never anything out there for him - nobody seemed to be interested.

"So we were worried the inquest would just be another one of those situation, but I'm very pleased to see a report has been done."

Mrs Bradbury said her son's case had demonstrated a lack of understanding of neurodivergence - believing her son's autism had limited his access to support and hampered investigations into a number of assaults he had suffered.

She said the issue surrounding mental ill health was a particular worry.

She said: "It is really concerning how often this could happen and how many calls might not be attended when people need help because they have a mental illness.

"There are also big questions about how neurodiverse people are categorised.

"There needs to be so much more understanding of mental illness, how devastating it can be and how quickly it can deteriorate."

Previously, she had spoken of her son's "deep connection" with animals, particularly when he was growing up, recalling a time a mole had approached him in the wild and allowed him to pick it up.

Who has received the report?

Mr Leach's report has been sent to three organisations, which guide ambulance trust's nationwide.

It has been sent to the Emergency Call Prioritisation Advisory Group (ECPAG), an independent committee which guides the NHS in setting 999 call priorities.

Mr Leach has also issued the report to the Association of Ambulance Chief Executives and the National Ambulance Service Medical Directors.

Each organisation has until December 19 to publish formal responses to the coroner's concerns.