“Firstly, evidence emerged during the inquest that the second call received by the WMAS…”
Dated 18 Sep 2017, from the coroner for Black Country. 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 13 Nov 2017.
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 dated18 Sep 2017
- Deadline13 Nov 2017
- Published on judiciary.uk25 Sep 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Midlands Ambulance Service University NHS Foundation TrustNamed in the report as “West Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in September 2017. |
The coroner’s concerns
– 1. Firstly, evidence emerged during the inquest that the second call received by the WMAS operator at 1921 hours had been incorrectly triaged as Level 3. The evidence of vomiting and drowsiness should have resulted in a Level 2 categorisation and therefore faster response time. 2. Evidence also emerged during the inquest that there were insufficient resources available and average response times of 29 minutes. This delay posed a risk to patients.
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, 2017-0214
- 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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