“The Investigation of the circumstances of the death has focused amongst other aspects on…”

The coroner’s concerns

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— The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen In that process. it Is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react In a different or more timely manner to the facts and detail being presented in the course of these calls. Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s side. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented. An apparent toxicological aid was either unappreciated or misinterpreted as an under assessed and immediate event- the need was obvious a} No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise. b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger c}) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger. There appears to be a need for a closer liaison and working relationship between Emergency Services which Is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent.

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, 2019-0420

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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