An inquest into his death heard there was a lack of information sharing between healthcare services, and the severity of the 23-year-old’s condition was not recognised.
The death of another young man from Nottingham saw a similar chain of events, and both prompted a coroner to issue a prevention of future deaths report – which is sent when a coroner thinks action is needed to protect lives.
Both services apologised and NEMS promised change.
Mandhar, who has been at the heart of those changes at NEMS, cried in the coroner’s court as she apologised to the families on behalf of the service, and was praised by families for her candour.
The coroner welcomed the “detailed review” by NEMS following the men’s deaths and its “robust internal action plan” to address the issues raised.
“We play a pivotal role in ensuring we work really closely with our primary care as well as our secondary care colleagues,” Mandhar said.
“We understand their pressures, we understand what they can facilitate and what they can’t and we look as to how we can mould our services to fit the changing landscape.”