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Coroner’s reportPrevention of future deaths · 2023-0506

“5 (1) The ambulance service was called at 2049 on 14 November 2022 and the call was…”

Dated 1 Dec 2023, from the coroner for South Yorkshire West. Sent to 2 organisations or people.

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

Deadline passed

Replies were due by 26 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.

  1. Report dated1 Dec 2023
  2. Deadline26 Jan 2024
  3. Published on judiciary.uk11 Dec 2023
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
NHS South Yorkshire Integrated Care BoardNamed in the report as “South Yorkshire Integrated Care Board”Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 26 Jan 2024. A reply may have been sent and not yet published.
Department of Health and Social CareResponse publishedPublished on judiciary.uk in December 2023.

The coroner’s concerns

– 5 (1) The ambulance service was called at 2049 on 14 November 2022 and the call was graded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0044 on 15 November 2022. (2) YAS were not resourced to respond to the number of emergency calls. (3) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.

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, 2023-0506
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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