“Andrew died on 10 October 2019 as a result of 1a) Respiratory Failure due to Upper Airway…”

The coroner’s concerns

Andrew died on 10 October 2019 as a result of 1a) Respiratory Failure due to Upper Airway Obstruction due to 1b) Peri-Tonsillar Abscess. He called 999 himself. Delays in the arrival of the ambulance contributed to the death. The evidence from the ambulance service, North East Ambulance Service, was that he had been correctly triaged under the pathway algorithm to a Category 2 response. I am concerned that, according to the evidence I heard in relation to the pathway algorithm, choking due to intrusion of a foreign object generates a category 1 response whereas choking due to a preventable but equally life-threatening natural cause generates only a category 2. The evidence from NEAS was that because Andrew was making the call himself and that it was not made by a third party was material to categorization, therefore I am also concerned that simply because he self-helped that this somehow reflected in a lower categorization. Finally, I am also concerned that a clearly life threatening condition, albeit preventable with critical care intervention, which in the event proved fatal in this case, is treated as a warranting a category 2 response rather than category 1. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: [please do not use individual’s names, but instead roles/titles]   Andrew’s family NEAS - I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Crispin OLIVER Senior Assistant Coroner for County Durham and Darlington

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, 2026-0383

Added to Minute Book

7 Oct 2026

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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