This case study reviews the system and the processes that led to the botched implementation. The London Ambulance Service have spent the best part of the last fourteen years attempting to computerise their despatch system. (They are still trying). The infamous failure of the second attempt was selected due to the multitude of issues and considerations it raises. The prevailing culture and the financial climate played a major role in shaping the events that led to disaster. This case study highlights how circumstances can gang-up and the resulting implications to the health and safety of patients.