“(brief summary of matters of concern) Mr Vincent had fallen many hours prior to making…”
Dated 7 Nov 2023, from the coroner for Bedfordshire and Luton. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 2 Jan 2024. A reply may have been sent and not yet published.
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.
- Report dated7 Nov 2023
- Deadline2 Jan 2024
- Published on judiciary.uk8 Nov 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| East of England Ambulance Service NHS Trust | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Jan 2024. A reply may have been sent and not yet published. |
| Royal College of Emergency Medicine | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Jan 2024. A reply may have been sent and not yet published. |
| Association of Ambulance Chief Executives | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Jan 2024. A reply may have been sent and not yet published. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 2 Jan 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
(brief summary of matters of concern) Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored.
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, 2023-0432
- 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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