Health chiefs admit errors and delays in case of man stabbed to death by son
The Ambulance Service and Northern Trust admit that mistakes were made and there were "unnecessary delays" in helping a mentally ill man who went on to stab his father to death, an inquest has heard.
Retired RAF technician John Lamont (64) died outside his home at Carvale in Ballymena in January 2013 after his son, Gregory, stabbed him nine times because he believed "Jesus was coming for him". The 29-year-old also stabbed his mother Liz (62) and killed the family dog.
He was cleared of murdering his father and attempting to murder his mother in 2014, on the grounds that he did not appreciate that what he was doing was both morally and legally wrong.
Dr Nagaiah Jayaprakash - a GP from Dalriada Urgent Care called out to assess Gregory - and Mrs Lamont raised concerns that delays in getting Gregory admitted to hospital and other delays by the Ambulance Service and PSNI contributed to Mr Lamont's death.
After arriving at the house shortly after 1am, Dr Jayaprakash assessed Gregory and then phoned the bed manager at Holywell Hospital to tell him that he needed a bed for a detained admission.
He told the coroner that he had told nurse Alan Brown that he would sign the form alongside Gregory's mother and a social worker would not be required.
Mr Brown said he was "very confused" by the phone call and thought it was a voluntary admission. He contacted the Crisis Response Team, who contacted Dr Jayaprakash and arrangements were made to admit Gregory.
Divisional Director of Mental Health Services at the Northern Health Trust, Oscar Donnelly, said: "That should not have happened. It should have been a single call from the GP." He apologised to Mrs Lamont for the "unnecessary delays" and said the case had been reviewed and a number of new procedures introduced.
Nigel Ruddell, assistant medical director for the Ambulance Service, told the coroner that when Dr Jayaprakash's driver phoned 999 to ask for an ambulance to transport Gregory to hospital, he was told that they could only take patients to accident and emergency and as this was an arranged admission, they could not help. The call handler then told the doctor he would have to speak to the Regional Pressures Coordination Centre. The wait for that was one to four hours.
Dr Ruddell said this had been incorrect and described it as an "error of judgment by the first call taker" as doctors can direct ambulances to any hospital.
He said the case had been subject to a review and he had made a number of recommendations based on this incident.
Marie Nugent, investigating officer for the Police Ombudsman, said two phone calls were made to the police as the doctor and his driver understood the ambulance could not arrive before police.
She said the first call was made to a non-emergency number and was given priority status as it was not an emergency at that stage.
During the second call, it became clear that the situation had escalated and police were dispatched immediately.
Coroner Samantha Anderson said Mr Lamont's death had been caused by stab wounds to the chest and abdomen.
She was satisfied there had been a "full multi-agency investigation" but said the incident had "changed Mrs Lamont's life forever".