'Over-complex' NHS led to man's death, says Cumbria coroner

BBC News

17-07-2025

An "over-complex" NHS system played a "major" role in the death of a 79-year-old man, a coroner has said.Thomas Mallinson died on 23 November at Cumberland Infirmary in Carlisle following a lack of "effective response or treatment" from health services for four days, according to assistant coroner for Cumbria Dr Nicholas Shaw.He said the case was an example of how "over-complexity has lost sight of a man's urgent care needs".The coroner issued a future deaths report on Tuesday, outlining the various treatment delays that Mr Mallinson faced.
Dr Shaw said the 79-year-old became unwell on 17 November with vomiting and diarrhoea.The following day, his wife called to request a GP appointment but was told there were none available that day and to call 111 instead.Following the 111 call, an ambulance was sent and Mr Mallinson was found to be healthy enough and told to call again if his symptoms persisted.
'Calls never came'
Still feeling ill the next day, Mr Mallinson attended a telephone GP appointment and was prescribed anti-diarrhoeal medicine.On the fourth day, Mr Mallinson continued to get weaker and so his wife called 111 again. She was told he would get a GP appointment the same day and to wait for a call back. Dr Shaw said that call never came.Mr Mallinson's wife then called 999 just before midnight. She was told by North West Ambulance Service (NWAS) that a doctor from Cumbria Health, the out-of-hours provider, would call back within two hours.Mr Mallinson's wife waited up until 04:00 GMT, but that call also never came.On the fifth day, following a night of "continuous vomiting and diarrhoea", Mr Mallinson's wife called the GP and was offered an afternoon appointment.She then called 999 again and an ambulance was sent.
'Where does responsibility lie?'
Mr Mallinson was taken to hospital immediately, where he was found to have symptoms including hypothermia and failing kidneys.He died in hospital two days later, the coroner said, adding that if Mr Mallinson had received treatment in a "timely manner" he most likely would have survived.Dr Shaw said the GP practice, run by provider SSP Health, had acknowledged Mr Mallinson should have been offered an in-person appointment rather than a telephone one.He also said he understood it was "impossible" for clinicians at Cumbria Health to answer and triage all the calls it received that night, as well as treat their caseloads. He said he was also concerned there was no way for NWAS to know that Mr Mallinson had not been tended to that night. "Where does responsibility lie?" the coroner asked.Dr Shaw said Mr Mallinson's death was an example of what happens when an "over-complex" system failed someone.SSP Health, Cumbria Health, NWAS and the Department for Health and Social Care (DHSC) have 56 days to respond to Dr Shaw's report.NWAS offered its condolences and said it was considering the report. Cumbria Health said it "acknowledged" the coroner's conclusions and was working to ensure his recommendations were met. DHSC and SSP Health have been approached for comment.
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