“e That the delay in attending and transferring Mr Nute increased his risk of not…”
Dated 24 Jun 2016, from the coroner for Cornwall. Sent to 2 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
Deadline passedReplies were due by 19 Aug 2016. 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 dated24 Jun 2016
- Deadline19 Aug 2016
- Published on judiciary.uk24 Jun 2016
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Western Ambulance Service NHS Foundation TrustNamed in the report as “South Western Ambulance Service” | Response publishedPublished on judiciary.uk in June 2016. |
| Devon and Cornwall Police | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 19 Aug 2016. A reply may have been sent and not yet published. |
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.
— e That the delay in attending and transferring Mr Nute increased his risk of not recovering from his fall/fracture or the trauma of the incident which in turn increasing his risk of death. e That the 999 calls from the public were not triaged by the call handlers at BT or South Western Ambulance appropriately and managed. e That South Western Ambulance did not inform the police of a road traffic accident in a timely fashion resulting in the scene of the incident/patient and late arrival of the ambulance not being managed appropriately. For example the witnesses to the road traffic accident were left waiting a good number of hours for the police to arrive to provide their details to them and there was no one to professionally manage the safety/dignity of Mr Nute who was lying on the highway.
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, 2016-0229
- Added to Minute Book
- 8 Oct 2026
- Reuse
- 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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