“In the course of the Inquest hearing, it became apparent that the NWAS electronic record…”
Dated 12 Nov 2014, from the coroner for Preston and West Lancashire. 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
Deadline passedReplies were due by 7 Jan 2015. A reply may have been sent and not yet published.
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.
- Report dated12 Nov 2014
- Deadline7 Jan 2015
- Published on judiciary.uk12 Nov 2014
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Ambulance Service NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 7 Jan 2015. A reply may have been sent and not yet published. |
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) In the course of the Inquest hearing, it became apparent that the NWAS electronic record referred to an ECG having been carried out on Mr Ince by the ambulance staff at 11.35pm, prior to his first admission to A&E. However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personne! on arrival at RPH, and no ECG trace was handed over or seen by A&E staff. (2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department.
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, 2014-0497
- Added to Minute Book
- 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
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