“The original call mace by J was allocated a priority green status which meant that should…”
Dated 16 Dec 2013, from the coroner for Oxfordshire. 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 10 Feb 2014.
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 dated16 Dec 2013
- Deadline10 Feb 2014
- Published on judiciary.uk16 Dec 2013
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Central Ambulance Service NHS Foundation Trust | Response publishedPublished on judiciary.uk in November 2017. |
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The coroner’s concerns
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— (1) The original call mace by J was allocated a priority green status which meant that should a higher priority call be received (a red status call) then an ambulance would be diverted, which ts what happened on two occasions. An | internal audit of that cail suggests that a different priority could have been Given to | the original call and the presenting concerns of Mr Gould's status. | recommend that SCAS review how they allocate priority to calls such as this one and identify whether any improvements to the allocation of priority should be given. (2) In evidence before the inquest SCAS indicated that there was little resilience in the system to tolerate absence or sudden sickness of personnel at certain times. My recommendation is that SCAS look at the resilience, particularly in rural areas, to consider whether further resources may need to be deployed. (3) The evidence from the family at the inquest was that they were informed that an ambulance would be arriving shortly. Had they known that there was to be the delays that occurred because other calls had been given priority, they informed me that they could have used first aid resources availabie to them within the village, | such as locally trained first aiders etc. My recommendation is that SCAS review what information they give callers and to consider whether communication in relation to estimated times of arrival should be notified to callers or the possibility of delays.
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, 2013-0357
- 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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