“During the inquest, evidence showed:1”
Dated 16 Sep 2019, from the coroner for South Yorkshire West. 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 11 Nov 2019.
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 Sep 2019
- Deadline11 Nov 2019
- Published on judiciary.uk1 Nov 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Yorkshire Ambulance Service NHS TrustNamed in the report as “Yorkshire Ambulance Service” | Response publishedPublished on judiciary.uk in November 2019. |
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
– During the inquest, evidence showed:1. that the pressure on resources was high that day. 2. that a review at the two hour point should have taken place to ascertain if the matter needed re categorisation. 3. Such a review didn’t happen. 4. Whilst the evidence at inquest was that this is unlikely to have changed the outcome in this case, it was a concern to me that it could be in another case.
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, 2019-0300
- 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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