“1 THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRlGHTON BN23QB VERONICA HAMILTON-DEELEY DL…”

The coroner’s concerns

1 THE CORONER'S OFFICE WOODVALE, LEWES ROAD BRlGHTON BN23QB VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARlNE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FR( __ GILV A D.J.TISSHA W, BA(LAW)HONS At the Inquest into the death of Mr Funnell I heard that the ambulance have introduced a relatively new system of dealing with calls and it seems to me timely to write now because it was a matter of concern to me that the ambulance was so delayed in its response to Mr Funnell. You will be able to see the basic facts in Part 3 of the Record of Inquest. This was an older man with an obvious head injury lying in the public highway on a freezing cold night. The first call was at 23:36 and was apparently graded with a 30 minute response (I know that 30 minute responses do not exist now but they did at the time that we are talking about i.e. in October 2017). If the ambulance had arrived within the 30 minute response time it would have been at the scene by no later ten past midnight. At 16 minutes past midnight there was a second call, firstly to ask where the ambulance was and secondly to explain that Mr Funnell was now vomiting and there was blood in his vomit. This was not flagged up and I was told at the Inquest that if it had been, it would have upgraded the call. Therefore, following Call 2 there was no change in status, the caller was told to ring again if things got worse, an apology was given but there was no estimated time of arrival. Call 3 came in at 00:34 hours, i.e. 58 minutes after the first call to say that the patient was now unconscious. This call was upgraded to what was a Red 1then and what I understand would be a C1 now. That is to say it was upgraded to an 8 minute response from 00:34 so the ambulance should have been there by 00:42 and in fact an ambulance arrived at 00: 51. This is really a shocking performance. Apparently there has been an audit and Cal 1 passed the audit; I cannot think why. There was no inability to triage the call but no-one was assigned so effectively that call was abandoned. With regard to Call 2. Effectively Call 2 was also abandoned. Your Legal Advisor at the Inquest took issue with my using the term "abandoned" however, it seems to me that that is exactly what happened and if there had not been a third call (all these calls were made by complete strangers to Mr Funnell who just found him lying in the road as they were corning and goitl.fl about their 2 THE CORONER'S OFFICE WOODYALE, LEWES ROAD BRIGHTON BN23QB VERONICA HAMILTON-DEELEY DL, LL.B. Her Majesty's Senior Coroner for the City of Brighton & Hove Telephone: Brighton (01273) 292046 Fax: Brighton (01273) 292047 Assistant Coroners CATHARlNE PALMER LL.B (HONS) KAREN HENDERSON, BSC,BM,MRCPI,FR( __ GILVA D.J.TISSHAW, BA(LAW)HONS business; it was they who took care of him, accepted responsibility for him, tried to keep him warm, tried to keep him comfortable, tried to keep him safe and they should be able to rely on a good ambulance response in those circumstances) it seems possible that he might have been left in the street for maybe another hour at least. I was told that the only way you can interrupt the system is by flagging up the need explained that during each shift a for a clinician. If that is not done, clinician will look at the stacked calls and will call back and make a decision about whether or not to upgrade the call. I was told that the fundamental problem was that the original triage was probably wrong and in any event there were no 30 minute responders available at that time. I was also told that the call taker can always use their initiative and ask a Clinician to come and intervene and advise them. agreed that it would be useful if there was more training for the call takers so that they did not feel inhibited from involving the clinicians in potentially difficult calls. During the course of my summing up I expressed the view that for Mr Funnell in this particular case, the Pathway system that SECAMB uses was not fit for purpose and in any event seems unsuited, without modification, to an emergency service.

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, 2024-0095

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0