“Although it could not be safely said when the deceased died, and therefore it could not…”
Dated 22 May 2023, from the coroner for Suffolk. 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 publishedOrganisations 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 May 2023
- Deadline17 Jul 2023
- Published on judiciary.uk9 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in May 2024. |
| East of England Ambulance Service NHS TrustNamed in the report as “The East of England Ambulance Service NHS Trust” | Response publishedPublished on judiciary.uk in May 2024. |
The coroner’s concerns
– Although it could not be safely said when the deceased died, and therefore it could not safely be said that the delay in the ambulance response probably contributed to the death, the concern is that long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future. Bearing in mind the national ambulance target response time for a Category 2 call of an average of 18 minutes, with 90% of calls to be responded to within 40 minutes: The average Category 2 response time for the East of England Ambulance Service NHS Trust (‘EEAST’) in October 2021, the month of this death, was 56 minutes and 2 seconds. The same average time for January 2023, the most recent month for which data was available, was 49 minutes and 3 seconds. Every month since the deceased’s death, EEAST’s Category 2 response time has been above the 90th centile time of 40 minutes. The average EEAST Category 2 response time for a given month in the period from October 2021 to January 2023 is over 1 hour, with a standard deviation of about 20 minutes. Therefore, EEAST’s Category 2 response time remains persistently and consistently far off target. Although I accept on the evidence that action is being taken, on both local and national levels, to prevent future deaths as a result of this issue, the evidence of the results of such actions to date is that these actions have been demonstrably ineffective and have not resulted in a Category 2 average response time for EEAST that is even close to the target time. The evidence received was that this issue, and the causes for it and the action required, are not just local in nature, but also national.
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, 2024-0238
- 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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