Two police officers have been disciplined following a mix-up over 999 calls - leading to a delay of over an hour in an ambulance being sent to an incident.
An English speaking Polish man called police on the 999 service at around 5.45am on 13 April 2008 to report that a work colleague had fallen down stairs. When no ambulance had shown up by 7.10am, the man called 999 again.
Police and an ambulance were then sent to the property, but the injured man was dead by the time they arrived.
A subsequent inquest established that the man had almost certainly died before the first phone call to police. The Coroner, however, asked that the Police Ombudsman investigate the circumstances of the delay.
Police Ombudsman investigators secured and analysed copies of the relevant 999 calls. Their enquiries established that the first call had been answered by an officer who dealt with the caller in a professional manner and said he was transferring the call to the ambulance service to deal with.
However, enquiries revealed that the call was not forwarded to the Ambulance Service. Neither were any details of the call entered on the relevant police computer system.
The caller rang back shortly after 7am to ask why an ambulance had not arrived, and this call was answered by another officer. As no information about the first call had been logged, that officer was unaware of the reported incident. This caused a further delay as the caller repeated information he had provided previously.
Enquiries also revealed that while the officer who took the second call dealt with it effectively, he had failed to speak to the caller in a professional manner.
Both officers have since been disciplined and the Police Ombudsman made a recommendation that the PSNI should review its 999 call handling procedures. The PSNI has since advised that it has introduced additional procedures to improve its 999 call handling systems.