An inquest has concluded the death of a student nurse in September 2015 could have been avoided if an ambulance had reached her sooner. Lisa Day had type 1 diabetes and had been ill and was vomiting blood. She asked a friend to call for an ambulance, which he did shortly after 5pm. He told NHS 111 that Miss Day had been vomiting blood for hours, had a headache and abdominal pain. He was told that an ambulance would be sent.

Five hours later the ambulance still had not arrived, by which time Miss Day had lost consciousness and was not breathing. Her friend immediately called 999 and started CPR until the first paramedic arrived but her condition deteriorated and she suffered a heart attack. She died five days later in hospital.

The coroner's court heard evidence that the initial call had been categorised as needing an ambulance within 30 minutes. The London Ambulance Service, however, gave evidence that it was "remarkably busy" that day, while NHS 111 said that computer systems had failed and assessments were being made on paper by non-medically trained call handlers.

The call handler discussed the case with a clinical adviser at NHS 111, a registered nurse, who did not ask about any pre-existing health problems but she did call Miss Day and established that she had type 1 diabetes. Miss Day asked for an ambulance but was told the service was extremely busy. The inquest heard that more could have been done to impress on her the need to get to hospital by other means if at all possible.

The coroner expressed her worry at the failure to recognise the seriousness of Miss Day's condition and to do more to advise others to try to get her to hospital, given the pressure on ambulance resources.

Andrew Clayton of Penningtons Manches comments: "A number of factors led to this appalling and avoidable outcome for Miss Day, none of which are new. Only two months later the London Ambulance Service was placed in special measures after the publication of a report by the Care Quality Commission (CQC) following an inspection in June 2015 that rated the service as 'inadequate'.

"Widespread public concern has been expressed about the fitness for purpose of the NHS 111 service and this case highlights that better safeguards are needed. There was a clear failure to establish at an early stage that Miss Day was at higher risk because of pre-existing type 1 diabetes and to take account of this in prioritising her.

“Type 1 diabetes is estimated to affect around 400,000 people in the UK and for NHS 111 staff to fail to recognise its potential significance and to stress the need to get Miss Day to hospital by other means is astonishing. This is a catalogue of errors blamed on resourcing issues and this tragic case must lead to changes of approach to protect patient safety as a matter of urgency."