Emergency phone lines should be changed to detect when calls go silent – FAI

Ambulance chiefs should consider improving phone lines to detect when calls have gone silent after a man died in his workplace while attempting to contact them, an inquiry has recommended.

David McClenaghan, a manager for car dealership Park’s Motor Group, died in his office at the company’s Kia showroom in Coatbridge, North Lanarkshire, on August 26 2018, a fatal accident inquiry (FAI) heard.

Mr McClenaghan, who was 57 at the time of his death, died after a cardiac arrest following a battle with deep vein thrombosis.

On Thursday, the FAI heard there would have been no way to save Mr McClenaghan’s life but Sheriff Paul Haran said telephone systems used by the Scottish Ambulance Service (SAS) should be improved in order for call handlers to detect when a call has disconnected or has gone silent.

Mc McClenaghan is understood to have dialled 999 after he began to fall ill, but given the severity of his condition, his call went silent, and the SAS was therefore unable to ask the necessary questions to discover his location.

According to the inquiry, the call handler did not consider that the call had gone quiet due to the worsening of Mr McClenaghan’s cardiac arrest.

However, an ambulance was sent out, but when it arrived at the dealership, the crew was unable to locate him upon arrival, and they later left the scene without exiting the vehicle.

His body was later found by the dealership’s security staff.

An FAI does not seek to attribute blame, but instead aims to establish the facts around the death, in turn making recommendations to prevent similar deaths in future.

Following publication of the determination, Andy Shanks, of the Crown Office and Procurator Fiscal Service, said: “We note the sheriff’s determination and the recommendation made for the Scottish Ambulance Service.

“The procurator fiscal ensured that the full facts and circumstances of David McClenaghan’s death were provided at the discretionary fatal accident inquiry.

“The determination has been provided to the representative of  Mr McClenaghan’s family. Our thoughts are with them at this time.”

An SAS spokesperson said: “We’d once again like to send our sincere condolences to Mr McClenaghan’s family for their loss. We know how difficult this FAI must have been and our thoughts continue to be with them.

“Whilst the inquiry found that nothing could have prevented the tragic death of Mr McClenaghan, there were lessons to be learned from it and since 2019 we’ve made significant improvements to our systems and procedures to enhance our response to 999 calls.

“We hope the forensic analysis of this case through the FAI will serve in providing answers and some comfort to all those involved in it. We welcome in particular the sheriff’s judgement that our staff acted at all times appropriately and reasonably given the information available to them at the time, following all procedure and protocols in place in 2018.

“We will work with BT and other partners in the coming weeks to explore the one single recommendation made by the inquiry relating to assessing whether further improvements can be made to the management of silent and disconnected calls, and will report our findings back to the procurator fiscal at the earliest opportunity.”