“NHS England”

The coroner’s concerns

– (1) NHS England. A call to the GP surgery the day before Richard’s death was taken by a receptionist who arranged a routine appointment. She was not a clinician and only had on the job training. The surgery has since introduced a system called Klinic which is safer. It prompts questions and uses an algorithm to alert any urgent or emergency calls that are then flagged. All calls are also reviewed by clinicians. However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgments as to the urgency of appointments, and there is no guidance available to surgeries as to how to mitigate the risks of this. 1 (2) London Ambulance Service. The GP called LAS concerned about Richard’s welfare. LAS attended his home address. Richard was not there. The LAS paramedic advised his sister to call the police. The LAS quality manager accepted in evidence that it would have been better to have taken her number and to pass it on to the police to make contact. I was told that national guidance on this issue was published in the summer. To date, neither guidance to crews nor to control had been updated to make the LAS guidance clearer to those applying it. (3) College of Policing. Due to the Covid pandemic, no ambulances were available when police attended to Richard. The Metropolitan Police Service had a policy that permitted conveying patients to hospital in an emergency if no ambulances were available. However, the policy included no practical guidance as to how that could be achieved mitigating the risks. I heard that the Metropolitan Police Service is updating the guidance. However, I am concerned that other forces across the country may also lack such practical guidance, which is of particular concern due to ongoing pandemic and the demands that may continue of ambulance services.

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, 2021-0335

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