“Despite giving a clear indication that he had taken an overdose of a lot of medication…”
Dated 10 Apr 2024, from the coroner for Manchester North. 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 5 Jun 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 dated10 Apr 2024
- Deadline5 Jun 2024
- Published on judiciary.uk29 Apr 2024
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Ambulance Service NHS Trust | Response publishedPublished on judiciary.uk in April 2024. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in April 2024. |
The coroner’s concerns
- 1. Despite giving a clear indication that he had taken an overdose of a lot of medication with an indication that he did so to take his own life the calls at 18.35 and 19.38 were both coded as category 3. 2. There was no involvement from a clinician at the time of either call. 3. Mr Dow was on his own in the hotel room. When a clinician called on 3 separate occasions there was no response. During her evidence Ms Lee, the Service Delivery Manager of the Emergency Operations Centre accepted that this could indicate that Mr Dow had lost consciousness but the call made at 18.35 was not escalated w
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, 2024-0192
- 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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