Man died after being told twice that no ambulance would be sent
A 55-year-old man died alone after making two calls to 999, during which call handlers informed him that no ambulance would be dispatched.
Brian Hurton suffered an aortic dissection—a tear in the body's main artery—on 18 November last year.
At 17:55, Brian contacted emergency services reporting difficulty breathing and feeling faint. He was advised that a clinician would return his call and instructed to call again if his condition worsened.
Approximately ten minutes later, Brian called again, stating he was "losing breath." Once more, he was told a clinician would call him back.
According to the transcript reviewed by BBC Scotland News, Brian was informed:
"We are quite busy in the area at the moment Brian, so based on the information provided instead of an ambulance response initially one of our clinicians is (going to) call you back."
An hour and 12 minutes after the initial call, a clinician returned Brian's call. However, Brian did not answer this call or two subsequent calls.
An ambulance was finally dispatched at 21:12 and arrived at 21:19—nearly three and a half hours after Brian's first call to 999.
Paramedics found Brian deceased on the bathroom floor of his East Kilbride home, where the front door was ajar.
'My brother died begging for help'
Brian's twin sister, Allison Duncan, was informed by her husband that Brian had died. She and her husband immediately went to Brian's residence.
Upon arrival, Brian's body remained at the scene, and police informed Allison that Brian had called 999 for assistance prior to his death.
The family requested an investigation into the circumstances surrounding Brian's passing.
Allison described listening to the 999 call recordings as harrowing.
"We couldn't believe it when we found out that Brian had made two calls and they then called him back and they couldn't get a response and it still took them another couple of hours before they sent an ambulance out to Brian's house."
"He was left with his last dying moments on his own, struggling for breath, begging for help, thinking that he was going to get help.
Then the second call, when they said again, they're not sending anybody out. It was clear in the audio that he gasped. He couldn't believe it.
He still said: 'Okay, thank you. Bye bye.'
I could see it in his face - he was terrified."
Allison expressed confusion as to why an ambulance was not dispatched immediately and suggested call handlers should have asked if someone could be with Brian, noting that Brian's twin brother could have reached him within seconds.
She reflected on Brian's death as "very sad" and "quite traumatising."
Allison also noted that although paramedics might not have been able to save Brian, they could have provided oxygen and pain relief to ease his discomfort, and he would have had someone with him during his final moments.
What did the review find?
A review conducted by Healthcare Improvement Scotland, seen by BBC Scotland News, found that Brian's initial 999 call should have been assigned a higher priority, which would likely have resulted in a timelier ambulance response. However, it was not possible to determine if this would have altered the outcome.
The clinical review response time exceeded expected waiting times.
Delays at the hospital reduced the ambulance service's capacity to respond to emergency calls awaiting attention.
The review recommended developing additional guidance for vulnerable patients who are alone and may deteriorate.
At the time, demand on the 999 service was lower than anticipated.
'Failure in call handling'
A spokesperson for the Scottish Ambulance Service stated:
"Due to the seriousness of this case, the Scottish Ambulance Service undertook a full Significant Adverse Event Review (SAER) rapidly, and we remained in contact with the family throughout the entire process.
We understand that nothing can change the outcome, but we hope that our adoption of the review's recommendations demonstrates our commitment to learning and improvement."
The spokesperson extended condolences to Brian Hurton's family and expressed willingness to discuss the review directly with them.
Health Secretary Angela Constance expressed sympathy to the family and acknowledged a failure in call handling.
"This should not have happened, and it is clear there has been a failure in call handling."
Constance welcomed the Scottish Ambulance Service's acceptance of the report and stated she would meet with them to discuss steps to improve call handling.
"SAS must learn from this investigation and I will be meeting with them to ask how they will be taking all appropriate steps to ensure improvements to call handling,"she said.
She noted that Accident & Emergency departments continue to experience significant pressure but emphasized that it is unacceptable for patients to wait too long for necessary care.
Constance announced that the Scottish government will introduce a new national plan for hospital flow, aiming to coordinate ambulance services and health boards to reduce patient wait times, avoid unnecessary hospital visits, and alleviate pressures in A&E.
