“Despite the fact that each different tablet could be fatal on its own, let alone…”
Dated 10 Apr 2014, from the coroner for Manchester City. 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 5 Jun 2014.
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 dated10 Apr 2014
- Deadline5 Jun 2014
- Published on judiciary.uk10 Apr 2014
- Today22 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| North West Ambulance Service NHS TrustNamed in the report as “North West Ambulance Service” | Response publishedPublished on judiciary.uk in April 2014. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
1. Despite the fact that each different tablet could be fatal on its own, let alone together, this call was given a code green. 2. This was an emergency and a delay of 2 hours and 38 minutes is totally unacceptable regardless of pressures on the service due to Halloween. 3. There appears to have been a lack of communication. The call handler believed that a response vehicle would be dispatched in 20 minutes. 4. The computer generated codes are misleading. One death is one too many when it should have, and could have been avoided.
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, 2014-0162
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
Something wrong, such as a date or who it was sent to? Report a mistake
Is this report about someone close to you? You can ask us to remove names from our pages.
Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use