“There is no detailed organisational understanding of the extent of the issues identified…”
Dated 25 Sep 2025, from the coroner for Nottingham City and Nottinghamshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 20 Nov 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated25 Sep 2025
- Deadline20 Nov 2025
- Published on judiciary.uk29 Sep 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Midlands Ambulance Service NHS TrustNamed in the report as “The Chief Executive, East Midlands Ambulance Service NHS Trust (‘EMAS’)” | Response publishedPublished on judiciary.uk in September 2025. |
The coroner’s concerns
1. There is no detailed organisational understanding of the extent of the issues identified in this case – that of the very limited assessment of a child or young person, the reliance on the incorrect physiological scoring system used, and the non- conveyance decisions made. 2. There is insufficient audit and monitoring of EMAS operational staff by senior clinical staff, to ensure there is both understanding and following of key EMAS guidelines 3. There is insufficient continuing professional development for operational staff in respect of the assessment of sick children and young people, with frontline staff having limited knowledge and understanding of the Children and Young Persons clinical guideline (that includes the importance of listening to parents, physiological scoring systems in children, and the significance of a change in mental state of a child or young person) I am not reassured that necessary actions to address these serious issues identified are in place.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0481
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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