Coroner questions four-hour delay in paramedics getting to Wigan borough mum after overdose

A coroner wants to know why ambulance staff waited four hours to ask police for help to get into a house where a mum had taken an overdose.

An inquest into the death of 26-year-old Jessica Ellison was adjourned when Prof Dr Alan Walsh discovered the delay.

He wants to know whether the same thing could happen again, potentially putting lives at risk.

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Bolton Coroner's Court

Bolton Coroner’s Court heard Jessica phoned 999 at 1.35pm on May 15 after taking an overdose of medication at her home in Atherton.

Records showed the call was not “triaged” until 2.15pm and when an ambulance went to the house, the crew could not get inside.

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Police coroner’s officer Marcheta Hogan said neighbours told paramedics to go to Jessica’s grandparents’ home, where she had been staying, and staff in the ambulance control room tried to phone her.

It was only at 5.27pm that police were contacted, with officers arriving at 5.48pm and forcing entry.

Prof Dr Walsh described this as a “missed four hours”.

He said: “What I am concerned about is it may be that there needs to be a review of some systems here that might help others in similar situations and it may allow me to refer these matters to the ambulance service for there to be a quicker report to the police and a more positive and proactive involvement and that might save some lives in future.”

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He adjourned the hearing so information could be gathered from the ambulance service and police.

The inquest heard Jessica had a psychotic illness and was an inpatient at Atherleigh Park from January 7 to April 26.

Her condition was initially “unstable” and she did not always take medication, but her mental health improved and she was eventually discharged.

Katie Smith, a senior nurse practitioner with the recovery team, had regular contact with Jessica.

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While Jessica still struggled at times, when Mrs Smith last saw her on May 12 she was “bright”, “very attentive” with her son and hoped to move house.

Jessica’s grandfather Chris Roberts also said she seemed to be doing well.

She spent the morning of May 15 with her five-year-old son, before asking Mr Roberts to collect them at 12.45pm.

He said he was “confused” when she asked him to take her to her house, as she did not like to be there, and he promised to call her at 3pm.

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But she did not answer and an ambulance later went to his home to tell him what had happened.

Jessica was taken to Royal Bolton Hospital and had two seizures in A&E, the inquest heard.

She was taken to the intensive care unit, where she was placed in an induced coma.

Her condition was not initially considered life-threatening, but attempts to discontinue sedatives were unsuccessful and she developed pneumonia.

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Jessica’s health deteriorated “rapidly” on May 23 and she died at 4.45am.

Analysis of blood samples showed she had taken anti-psychotic drug quetiapine at a level “highly suggestive of excessive use”. This had previously been prescribed, but she may have “stockpiled” it.

Jessica had also taken prescribed amounts of other medication – but pathologist Dr Ravindra Sawant said they may have contributed to the effect of quetiapine.

He found she died of combined drug toxicity.

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The inquest will resume on Tuesday, October 11.