“The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived…”
Dated 27 Apr 2022, from the coroner for South 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.
The 56-day response deadline
All responses publishedReplies were due by 22 Jun 2022.
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 dated27 Apr 2022
- Deadline22 Jun 2022
- Published on judiciary.uk5 May 2022
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| London Ambulance Service NHS TrustNamed in the report as “London Ambulance Services NHS Trust” | Response publishedPublished on judiciary.uk in May 2022. |
The coroner’s concerns
– (1) The evidence of the medical expert was that Mr Gill was so unwell by the time he arrived at hospital that it was more likely than not that his life was not rescuable with sooner treatment. Whilst Mr Gill was taken to hospital, it was not under blue lights and sirens, and the most senior clinician drove so was not on hand to provide emergency treatment that the technician was unqualified to provide. It was apparent that the ambulance crew were not aware that the combination of seizures and cocaine represented a medical emergency, a fact expressly found in the jury’s conclusion. (2) Whilst it was reasonable for the LAS staff to suspect a link between the arrest and seizures, the arrest unduly influenced the assessment of urgency.
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, 2022-0131
- 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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