The sister of a man who died while waiting for an ambulance has expressed her family's ongoing grief, describing how they live each day knowing his death could have been avoided. Lee Gannon, aged 25, passed away at the Royal Victoria Hospital in February 2022 following breathing difficulties at his Belfast home. A post-mortem examination determined he died from lobar pneumonia, a severe bacterial infection. His family summoned an ambulance, but the call was not classified as a Category 1 emergency—the highest priority level for immediately life-threatening medical conditions—and Lee did not arrive at hospital for nearly four hours after making the initial 999 call.
At the inquest hearing, coroner Marie Dougan concluded that the delay in ambulance response "materially contributed to his premature death." Colleen, Lee's sister, emphasised that her brother was far more than a statistic or a recorded call in the ambulance service's system, but rather a deeply loved family member known for his kindness and humour. Both Colleen and their father Colum were informed during the inquest that their family's response—which involved making four separate 999 calls and administering chest compressions—represented the correct course of action.
How did the emergency response fail?
The initial 999 call made by the family should have been registered as Category 1, reserved for immediately life-threatening medical emergencies, but it was not. According to emergency service reporting, Category 1 calls should be answered within eight minutes, while Category 2 calls should be answered within 18 minutes. The ambulance operators missed two subsequent opportunities to reassess and re-triage the case when the family described Lee's deteriorating condition. Only after the fourth 999 call was Lee re-triaged as Category 1, but by the time paramedics arrived, it was too late.
The first emergency call was placed at 00:19, yet Lee did not reach the Royal Victoria Hospital until 04:13—a gap of nearly four hours. Coroner Dougan stated:
"I find that the incorrect categorisation of the initial 999 call and the subsequent failures to re-triage the deceased resulted in a substantial delay in ambulance attendance and transfer to hospital. That delay deprived the deceased of timely and appropriate assessment and treatment at the Royal Victoria Hospital for pneumonia and sepsis and materially contributed to his premature death."
Medical evidence presented to the inquest proved significant. According to clinical testimony, Dr Mohamed Al-Aloul told the court that, on the balance of probabilities, timely assessment and treatment would have produced a different outcome and Lee would likely have survived.
What systemic problems did the coroner identify?
Dougan highlighted that this was not an isolated incident. She noted that delays in ambulance response times had featured in multiple inquests, and prolonged delays in handing over patients to Emergency Departments remained a widespread problem across Northern Ireland.
"The evidence before me demonstrated the significant effect which prolonged hospital handover delays can have upon the availability of ambulance resources to respond to patient in the community,"the coroner said.
Northern Ireland Ambulance Service (NIAS) leadership acknowledged the failures during the inquest. According to service statements, ambulance chief Neil Sinclair told the inquest that the service had been delivering "below standards and targets" because crews were delayed outside overcrowded emergency departments, reducing availability for 999 calls. The service accepted responsibility and committed to learning from Lee's death.
What was Lee's family background?
The court heard that Lee's mother Anne was devoted to her son and that he was affectionately known as a mummy's boy who loved living in the family home. Coroner Dougan expressed deep sadness that Anne had not survived to hear the inquest findings, as understanding what happened to her son that night had been her wish.
What does the broader evidence show about ambulance delays?
Lee's case reflects a wider pattern of ambulance service difficulties in Northern Ireland. A Northern Ireland Audit Office report found that ambulance handover delays in the region had worsened significantly in recent years and were causing harm to patients. However, the Audit Office later reported that ambulance handover times and emergency response times had seen "a dramatic improvement" in recent months following actions taken by the ambulance service.
This case is part of a series of inquests examining whether delays in emergency response contributed to preventable deaths. Similar cases have raised questions about call handling procedures and ambulance dispatch protocols across the UK health system.
Key Facts
- Lee Gannon died in February 2022 from lobar pneumonia after a nearly four-hour delay between the first 999 call and hospital arrival
- The coroner found the initial emergency call should have been classified as Category 1 but was not, and two further opportunities to re-triage were missed
- Medical evidence indicated Lee would probably have survived with timely treatment
- The Northern Ireland Ambulance Service acknowledged failures and committed to improvements
- Prolonged hospital handover delays remain a systemic problem affecting ambulance availability across Northern Ireland
