“(brief summary of matters of concern) Regulation 28 – After Inquest Document Template…”
Dated 22 Jan 2024, from the coroner for Teesside and Hartlepool. 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.
The 56-day response deadline
All responses publishedReplies were due by 18 Mar 2024.
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 dated22 Jan 2024
- Deadline18 Mar 2024
- Published on judiciary.uk25 Jan 2024
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social CareNamed in the report as “Department of Health & Social Care” | Response publishedPublished on judiciary.uk in January 2024. |
| North East Ambulance Service NHS Foundation TrustNamed in the report as “North East Ambulance Service Foundation Trust” | Response publishedPublished on judiciary.uk in January 2024. |
The coroner’s concerns
(brief summary of matters of concern) Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. The call handler did not detect a worsening condition and did not escalate the call from Category 2 to category 1. 2. The methods of detecting worsening conditions in existing category 2 calls are not sufficiently robust (dispatch clinician and numerous call condition). 3. The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.
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, 2024-0037
- 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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