Catalogue of errors followed Wigan borough mum-of-one’s massive overdose of prescription drugs

An inquest was re-opened into the death of 26-year-old Jessica Ellison, after it was adjourned last year when the coroner asked for more information into a four-hour delay between the initial emergency call being made by Ms Ellison and her admission to hospital.

The mum-of-one from Atherton had a history of mental health problems, including bipolar disorder and depression, for which she was on medication and had previously been treated as an inpatient.

On May 15 last year, she had visited a local park with her young son, now aged six. They were taken there and back by Jessica’s grandfather, Chris Roberts.

Mr Roberts, who attended the inquest at Bolton Coroners’ Court on Thursday with wife June, said at the time his granddaughter appeared normal.

However she had asked to be returned to her own home on Morley Street, rather than go back to her grandparents’ home where she and her son were living at the time.

While her son remained at his great-grandfather’s, Jessica was the only person in the house. Later in the afternoon, she made two 999 calls, telling call handlers she had taken an overdose and was suicidal.

However the call was mistakenly allocated by the North West Ambulance Service (NWAS) call handler as a non-critical emergency category three case, which meant Jessica could face a wait of ten-and-a-half hours for an ambulance to arrive.

Calls given a category one or two are prioritised and have a target of just a few minutes for an ambulance to arrive.

Even on the second call made by Jessica 20 minutes later, when she was more distressed and then suddenly stopped speaking, another call handler still marked it as category three and therefore non-urgent.

Because of the categorisation, a non-NWAS private ambulance with only basic facilities was sent to Jessica’s home two hours later.

On arrival, staff could get no response from inside the house.

It was only when they returned 90 minutes later that police officers were called to break in and Jessica was found unresponsive in a bedroom.

She was taken to Royal Bolton Hospital, where she died a week later from complications arising from a massive overdose of prescribed medication.

Coroner Prof Dr Alan Walsh said the way Jessica’s case had been handled was a “classic test case of how not to do the job".

Although it would not have changed the eventual outcome, he said there had been “inordinate and unacceptable delays” in her treatment.

He singled out the incorrect categorisation given by call handlers and the failure to call police to force entry earlier.

The cause of death was given as bronchial pneumonia due to combined drug toxicity.

Prof Dr Walsh concluded Jessica died by misadventure, as he was not satisfied she intended to take her own life and that the drugs overdose was a “cry for help.”

He said: “It greatly saddens me that she did this at the age of 26, and I have an even greater sadness for her son that he lost his mother in these circumstances.”

Speaking after the inquest, Jessica’s grandad Chris Roberts paid tribute to her “caring and compassionate nature.”