Ambulance 'neglect' as Brad, 19, found dead 10 hours after pal's chilling 999 call

A 'lovely' teenager died after no ambulance was sent to him for nearly 14 hours - despite two desperate 999 calls. Bradley Holder, 19, was acting erratically at a house in High Lane, Burslem, when the alarm was raised.

An inquest into his death heard he started to 'throw his arms around and was shouting and gurning'. According to witness statements, former Haywood Academy pupil Bradley, of Beaconsfield Drive, Blurton, was 'rolling around on the floor in shards of glass'. His breathing was 'off and on', and he was having seizures.

A first 999 call was made to West Midlands Ambulance Service (WMAS) at 7.26pm on December 18 2022 and recorded as category two.

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But when paramedics failed to arrive, a second call was made at 11.13pm. A friend told the operator 'there will be a death if an ambulance isn’t sent' - but still no emergency help came to his aid.

The following morning, Bradley’s friend found him on his back under the bed and was 'cold to touch'. A final call to WMAS was made at 9.04am on December 19 2022. Paramedics pronounced Bradley dead at the scene.

Paying tribute to her son, Bradley’s heartbroken mum Joanne Gillies said: “Bradley loved fishing and he loved football. He loved chilling and socialising with his friends.

"He was loving, caring, and outgoing. He was a good boy, a really bubbly boy, and a lovely son. If they’d answered that first call then they could’ve saved my son.”

A toxicology report found MDPHP (monkey dust), paracetamol and cannabis in Bradley’s blood. Malnutrition was also a contributing factor as Bradley’s BMI was a little over 13. A medical examiner told the hearing 'it can be reasonably assumed that his death would’ve been avoidable if the ambulance had arrived in a timely manner'. He added: "Therefore the delayed ambulance was a contributing factor to the cause of death."

Coroner Emma Serrano said: “It’s quite clear that Bradley had gone out and bought monkey dust. I’m satisfied that the cause of death was MDPHP with malnutrition as a contributing factor.

"We know an ambulance was called at 7.26pm on December 18 2022, and as a Category Two, an ambulance should’ve been there sometime between 7.46pm to 8.06pm.

“The second call should’ve been a Category One, and even after this second call an ambulance didn’t come. By 9.04am the following morning, Bradley’s friend found him deceased.

"The next thing I have to consider is neglect. I’m satisfied that there was a gross failure in care because Bradley was fit and healthy.

"Based on what the ambulance call said, an ambulance should’ve been with him by 8.06pm. Not coming at all to someone in a vulnerable position is gross failure neglect.

“I’m satisfied that if the ambulance had arrived in a timely manner his death could’ve been avoided. Bradley’s cause of death is recorded as MDPHP but gross failure neglect is a contributing factor.”

Jane Morris, WMAS investigations officer, explained the service was in high demand with 230 Category Two cases regionally, with 89 of those being in Staffordshire.

She told the hearing: “The calls were non-compliant because there was no attempt to speak to the patient, the process wasn’t explained to the caller, and nobody asked how deep the patient’s wounds were.

“The operator asked if anyone in the house could take him to hospital but they said 'no'. The first call was Category Two but the second could have been Category One [because of Bradley's seizures and struggles with breathing], but no ambulance was dispatched.

“At the time the service was in high demand. Category Ones were going out but were not reaching their target."

Ms Morris said changes had been made to cut ambulance delays. She said: "Back then there was huge demand on ambulances because of hospital delays. It still is now, but we’ve put things in place to handover within 15 minutes if a paramedic is finishing their shift.

“There are roughly 40 paramedics enrolled each month. We have expanded our fleet and aim for 350 ambulances in the West Midlands.

“We also have Hospital Ambulance Liaison Officers (HALOs) who speak to the hospital and try to get things moving. If it’s the end of a paramedic’s shift then more paramedics are sent to take them over, but if there are hours left of their shift then they’ll wait outside the hospital.”

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