A coroner has said there was a missed opportunity to deliver vital treatment to a man who died from meningitis after waiting nearly six hours for an ambulance.

Mthuthuzeli Mpongwana, 38, of Bedminster, Bristol, died in hospital two days after his wife, Lisa Armitage, 27, dialled the medical advice number 111.

Armitage called the number at 10.30pm on 5 January, reporting that her husband was suffering from a sore neck, struggled to look at light and had a bad headache.

She was advised to wait outside her home as a rapid response vehicle with blue lights on would attend, and warned that her husband could have meningitis.

Avon coroners court heard that the car did not arrive until 1.17am and paramedic Dana Noriega initially dismissed Mpongwana’s symptoms as “man flu”.

Noriega failed to spot that Mpongwana had signs of both sepsis and meningitis and downgraded the case to a 40-minute response at 1.50am.

He did not administer penicillin – which should have been given as soon as possible – until 3.30am and only requested a high-priority ambulance at 3.50am.

The ambulance finally arrived at 4.20am, by which time Mpongwana’s condition had deteriorated. He suffered a brain injury and died in hospital the following day.

Maria Voisin, senior coroner for Avon, reached a narrative conclusion at the inquest, in Flax Bourton, near Bristol, and ruled there were failings in his care.

“Mr Mpongwana died from natural causes contributed to by a failure to take appropriate action in the face of an obvious need,” Voisin said.

“That failure was at 1.50am on 6 January, when a P1 (high-priority ambulance) backup should have been requested and benzylpenicillin should have been administered. The inappropriate care that was given resulted in a missed opportunity for medical treatment to be given.”

Voisin said she did not consider that South Western Ambulance Service NHS foundation trust needed to take further action. The inquest heard that Noriega had left the trust since the incident.

Mpongwana’s wife called 111 at 10.30pm on 5 January after her husband complained that light from his mobile phone was hurting his eyes. The call was passed to the 999 service at 10.56pm, marked as a P2 – priority two – call, requiring a 30-minute response and checks on Mpongwana’s condition every 30 minutes.

However, the ambulance service was busy that evening and only one such welfare check took place, at 11.36pm, before any paramedics arrived. Noriega arrived at 1.17am, as Armitage was calling 999, and took a set of observations.

“Mr Mpongwana’s symptoms included a headache, light affecting his eyes and a fever,” Voisin said. “By the time the paramedic arrived he had also been sick and was finding it hard to stand.

“Regardless, Mr Noriega said that at 1.51am he requested a P3 vehicle and not a P1. He said this was because they were busy that night and he thought a P3 might get Mpongwana to hospital quicker.”

Noriega failed to administer benzylpenicillin until it was suggested by an out-of-hours doctor whom he had called for advice at 3.11am. He did not give Mpongwana the drug until 3.30am and failed to call for a P1 ambulance, which would arrive in 15 minutes, until 3.50am.

In interviews with South Western Ambulance Service following the tragedy, Noriega described Mpongwana’s condition as “typical man flu”, the coroner said.

The ambulance did not arrive until 4.20am and reached Bristol Royal Infirmary at 4.46am. Mpongwana had suffered a fatal brain injury and could not be saved.

Dr Dan Freshwater-Turner said the outcome might have been different if penicillin had been administered and Mpongwana had been taken to hospital earlier.

The consultant told the inquest: “We will always advise giving antibiotics as early as possible. It is possible if he had had treatment earlier that the outcome may have been different.”

Speaking after the inquest, Armitage said: “Mthuthuzeli and I had just settled into our new life in the UK together and he had just started applying for jobs. When he died I was working as a theatre assistant at St Michael’s hospital but have not been able to return to work as I find it too distressing seeing people having surgery as it reminds me of watching my husband lying motionless on a life-support machine.

“I am extremely concerned about the treatment he received by the ambulance staff and I was baffled at the time that they didn’t seem to be taking into consideration his symptoms and the urgency of his situation. I am still amazed now that the paramedics took such a long time to realise the red-flag symptoms of meningitis that Mthuthuzeli was experiencing and it took them six hours to send an ambulance.

“It is well known that you have to act quickly if someone starts to suffer from symptoms of meningitis and his death could have been avoided if they had taken the care and attention to give him the medical care he rightly deserved.”



Armitage was represented throughout the hearing by Julie Lewis, a partner and specialist medical negligence lawyer at Irwin Mitchell. Lewis said: “The family would like reassurances by the trust to ensure that all their staff are fully trained to notice and diagnose the symptoms of meningitis to prevent anyone else suffering from any similar issues.

“Sadly on this occasion the paramedics didn’t seem to recognise the symptoms of meningitis and should have followed the basic guidelines on treating someone with suspected meningitis and Lisa has suffered the consequences.”

A serious incident report carried out following the death found that Noriega was not familiar with guidelines for recognising and treating sepsis and meningitis.