“The failure by the Call Handler to give timely advice in respect of CPR”
Dated 21 May 2015, from the coroner for North Northumberland. Sent to 3 organisations or people.
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 16 Jul 2015.
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 dated21 May 2015
- Deadline16 Jul 2015
- Published on judiciary.uk21 May 2015
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East Ambulance Service NHS Foundation Trust | Response publishedPublished on judiciary.uk in May 2015. |
| Department of Health and Social CareNamed in the report as “Department of Health” | Response publishedPublished on judiciary.uk in May 2015. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in May 2015. |
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. The failure by the Call Handler to give timely advice in respect of CPR. 2. During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing. This fails to recognise the need for CPR in cases of Aganol (heavy/noisy breathing which is insufficient to sustain life). This fault was pointed out to Pathways by the Clinical Section Manager for North East Ambulance Service NHS Foundation Trust.prior to the latest update being installed in early 2014 (Update 9). Pathways refused to amend the system. That fault remains in place to date. 3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location 4. The target time for the arrival of the ambulance was 8 minutes, this was breached. The ambulance did not arrive for 15 minutes. S. During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East. 6. During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff.
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, 2015-0198
- 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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