“Ambulance crew updated EOC Mr Cooke could not be located”
Dated 8 Aug 2021, from the coroner for Mid Kent and Medway. 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 3 Oct 2021.
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 dated8 Aug 2021
- Deadline3 Oct 2021
- Published on judiciary.uk12 Aug 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South East Coast Ambulance Service NHS Foundation TrustNamed in the report as “South East Coast Ambulance Service” | Response publishedPublished on judiciary.uk in August 2021. |
The coroner’s concerns
– (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) (ii) (iii) 6 the matter was not escalated further when Mr Cooke could still not be located the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested.
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, 2021-0266
- 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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