“‘A root cause analysis comprehensive and independent investigation report undertaken by…”
Dated 23 Mar 2016, from the coroner for Teesside. 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 18 May 2016.
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 dated23 Mar 2016
- Deadline18 May 2016
- Published on judiciary.uk23 Mar 2016
- Today24 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 March 2016. |
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.
— ‘A root cause analysis comprehensive and independent investigation report undertaken by the North East Ambulance Service discloses that the reasons for the delay of the ambulance arrival include severe demand and shortages in the division. Road closures and diversions did not assist the crews.
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, 2016-0116
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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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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