“6 1”

The coroner’s concerns

– 6 1. Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance. 2. No 111/ambulance dispatch staff knew of or had been trained about the correct procedure to be adopted when trying to locate a potentially seriously ill patient when they had incomplete information as to that persons whereabouts. In short, they did not know how to obtain the callers address. Despite the considerable and well intentioned efforts of a number of people working in the call centre, these individuals failed to locate the deceased’s home address and as a result there was an inordinate delay before the ambulance crew were able to attend the deceased’s property. 3. When the ambulance service duty manager spoke to BT, that individual did not fully explain the nature and reason for the enquiry with the result that the BT operator was not seized of all relevant information with which he could make a fully reasoned decision as to whether to exercise his discretion or not to release the deceased’s home address to the caller. 4. A detailed investigation that was undertaken by North East Ambulance Trust is upon closer examination, in places lacking depth and incisiveness. 5. New revised North East Ambulance Service Trust protocols which are undated, and which were produced to the Senior Coroner only on the morning of the Inquest being resumed, do not deal with the problems identified in this case even though they were designed to address them. 6. The deceased died in November 2013 and within a day or two of the death being reported, it was clear that the circumstances of the death highlighted serious potential systemic failures and yet, no substantive further advice was given to control room staff until February 2014. 7. Upon receipt from BT of an email in February 2014 in which BT endeavoured to address the issues raised by this death, the North East Ambulance Service Trust, copied the email to senior managers and other staff (though it is not known who exactly) to advise them of the change of procedure but other than merely forwarding the email the North East Ambulance Service Trust did not take any steps to try and ensure that this potentially life saving information was known by all people who were involved in the call handling process. No specific training on this important issue has been carried out as at the date hereof and none was planned. 8. The response to the incident by the Trust appears perfunctory and now, eight months after the death of the deceased, notwithstanding the changes made to practice and procedure by the North East Ambulance Service Trust it is clear that a clear and robust policy and practice to address this issue is not 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, 2014-0348

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8 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