Amidst his grief, Lawrence Thorpe is angry. And he has every right to be.
If an ambulance had arrived at his mother’s home in Portsmouth, then he believes it could have saved, or prolonged, her life.
Instead one en route and just four minutes away from her front door was sent back following instructions from the NHS 111 service. This was despite the call being categorised as an emergency.
Ann Walters, who had a hole in her heart, had originally called 111 at 8.25am. But by the time an out-of-hours GP eventually arrived almost exactly 12 hours later, it was far too late.
Lawrence had found his mother on the floor at 6pm. She had died from heart failure.
Why was the ambulance recalled when it was so close to her home? And why did it take so long for other medical help to arrive? The GP said he was called at 4.45pm to see Ms Walters, but because of a high workload could not get to her until 8.30pm.
These are questions to which Lawrence and his sister Felicity want answers.
South Central Ambulance Service, which runs NHS 111, has now launched two investigations and we trust they will be exhaustive.
Lawrence says he has told his story so that lessons can be learned.
We certainly hope that is the case. But sadly this is not the first time that the 111 service has been in the headlines for the wrong reasons.
The line, which replaced NHS Direct as the number to call for urgent but non-emergency care, has proved controversial.
There have been complaints of calls going unanswered, poor advice and too many ambulances being sent out to trivial calls.
Meanwhile research has suggested that a phone line intended to lift pressures on hospital A&E departments has actually added to the burden.
We urge the government and NHS bosses to look again at the whole 111 system and do all they can to make it a service on which people feel confident they can depend in their hour of need.