“A serious level investigation report (reference SI 2018/27277) made 5 recommendations…”
Dated 19 Nov 2019, from the coroner for Lincolnshire. 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 14 Jan 2020. 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 dated19 Nov 2019
- Deadline14 Jan 2020
- Published on judiciary.uk28 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East Midlands Ambulance Service NHS TrustNamed in the report as “East Midlands Ambulance Service” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Jan 2020. A reply may have been sent and not yet published. |
| CAT | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Jan 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded? 6.
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, 2019-0392
- 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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