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Coroner’s reportPrevention of future deaths

“A call to the London Ambulance Service regarding a man who had been unconscious did not…”

Dated 19 Aug 2018, from the coroner for Inner North London. 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.

Read the full report on judiciary.uk

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The 56-day response deadline

Dates unclear

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.

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  1. Report dated19 Aug 2018
  2. Published on judiciary.uk19 Aug 2015

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Responses from each recipient

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Sent toResponse
London Ambulance Service NHS TrustDates unclearNo response published on judiciary.uk. The date on the report comes after the day judiciary.uk put it online, so we can’t work out when replies were due.

The coroner’s concerns

A call to the London Ambulance Service regarding a man who had been unconscious did not prompt a red prioritisation. You will remember that I wrote to you on 27 May 2015, regarding the assumption made by an LAS EMD that a child was asleep but rousable, when in fact the little boy was likely to have been unconscious. I am extremely concerned that a theme may be emerging in the handling by LAS of calls regarding unconscious patients. 2

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
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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