'My son died suddenly after collapsing at home - we were failed at every step'

A heartbroken mother has slammed authorities following her son's death after she was failed by multiple services - further delaying and heightening her grief.

Martyn Wright, 35, suddenly collapsed inside the family home in Cardiff, Walesin December 2022. His mother Claire and brother John attempted to save his life but were hit with delays by the ambulance services.

John administered CPRon his brother, alerting 999 and calling their mum Claire too. When Claire arrived around 25 minutes after John phoned her, she gave him mouth to mouth. Tragically, as the pair attempted to keep Martyn alive, they had no idea that an ambulance was nowhere near.

It was later found that an emergency call dispatcher had wrongly downgraded the call from the most serious to the least. Their ambulance had been diverted to another incident in response. It can never be known whether an ambulance could have saved Martyn'slifebut when the ombudsman investigated it said there was a "small possibility of a different outcome".

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In the months that have followed, the family claim they have been let down by whoever they turned to for help. There were errors in the way the two 999 calls were handled by the ambulance service, as well as issues with police, coroner, health board, GP, and even the undertaker who handed Martyn's father the wrong ashes when he went to collect them, reports Wales Online.

• The first 999 call was incorrectly downgraded from the most serious "red" priority to "green two" defined as being for "not clinically serious or life-threatening" which led to a 32-minute delay in an ambulance attending. The second call was not handled correctly with Claire given the wrong information about giving CPR. The ombudsman found this meant Martyn "did not receive timely medical attention".
• The ombudsman found that the paramedic did not enter "fully accurate information".
• Police never took a written statement from John in the immediate days after his brother's death but called him out of the blue eight months later. He then feared he had done something wrong in trying to save his brother's life.
• When Martyn's dad went to collect his ashes the undertaker handed over someone else's.
• His parents went to sign his death certificate twice because the registrar made a mistake on the first one.

Most upsetting for Claire, though, is that she wanted to see her son's body to say goodbye one last time. But when his body was transferred from the hospital mortuary to the funeral director's it had deteriorated to such a degree they told her not to see him.

She then discovered they should have been offered a visit while he was at the hospital but was told it had been suspended as the service was so busy. However, Claire then uncovered that visiting suspension only started two weeks after her son died. She was, in her words, "robbed" of the chance of a final goodbye.

It was reported that the call handler had to manually enter a code due to the system being down. That code translated to Martyn being "obviously deceased" rather than recently collapsed. When Claire had arrived, she found her son at the top of the stairs unconscious and his brother doing chest compressions. "He'd been doing that for over half an hour by now," she said.

Claire then rang 999 again and spoke to another operator. This time it was categorised as a "red" call and an advanced paramedic and ambulance were dispatched with arrival times of 12 and 16 minutes respectively. Claire was told how to do mouth to mouth but wasn't told to do CPR – another breach of protocol. When the first responder arrived 45 minutes after the first call, Claire describes her as having an "appalling" attitude.

John was still doing CPR and Claire was giving mouth to mouth. "She came up the stairs and we moved back for her to get to him and she sort of leant over Martyn and gave him a cursory look, didn't touch him, and said: 'Oh no – he's deceased'."

"He ( John) was exhausted, in shock, as was I, and the only comment she made was how thin he was. We just sort of looked at each other, John and I," said Claire. The family put a letter of complaint to the Welsh Ambulance Service Trust (WAST) before the end of the year. At that point their overriding question was trying to establish why an ambulance wasn't sent to the house when John first called.

Failings were found by the ombudsman in the way the first call by John was handled. The ambulance trust confirmed the first call handler had started work five weeks before Martyn collapsed and had completed a full three-week induction and was taking calls with supervision. The trust said she should have been provided with an appropriately-trained mentor on the day Martyn collapsed but sickness meant she was placed with someone who had not had training.

The trust confirmed their call handler had asked the wrong questions and not carried out their duties "appropriately" but said the call handler had now been given formal training on cardiac arrests. The trust also said the call handler's "buddy" had changed roles and was "unable to recall the incident".

In the conclusion, the ombudsman upheld the family's complaint and said the ambulance trust's response to Claire "fell well short of what the duty promotes and is intended to achieve". The ombudsman also said "disappointingly" the trust didn't provide all relevant evidence.

The records submitted were found not to be accurate with the paramedic saying there had been a 10-minute delay before CPR was started – something they admitted to the ombudsman was inaccurate.