“The inquest was told that due to significant demand the wait time for an ambulance in…”
Dated 3 May 2024, from the coroner for Manchester South. 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
Deadline passedReplies were due by 28 Jun 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.
- Report dated3 May 2024
- Deadline28 Jun 2024
- Published on judiciary.uk14 May 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Response publishedPublished on judiciary.uk in May 2024. |
| NHS Greater Manchester Integrated Care BoardNamed in the report as “Greater Manchester Integrated Care” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 28 Jun 2024. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. The inquest was told that due to significant demand the wait time for an ambulance in category 3 was in excess of 4 hours rather than the target 1 hour. The inquest was told that this was not unusual and was still an ongoing issue. The evidence was that this was not unique to NWAS but the general picture in England. The inquest was told that there had been improvements in category 1 and 2 response times but to achieve this category 3 calls continued to have these significant delays. 2. The inquest was told that the initial call to NWAS was made by the out of hours nurse. She made it clear that she felt the ambulance response needed to be within 1 hour. As this was in theory the response time consistent with a category 3 response, she accepted the categorisation. This acceptance did not appear to take into account that on that evening a category 3 call was not going to result in an ambulance within 1 hour. 3. The evidence before the inquest was that there were no specific sepsis trigger questions on the ambulance pathway. The nurse suspected sepsis and gave that indication but that did not trigger a faster response despite the recognition that where sepsis is suspected antibiotics need to commence as a priority. 2
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, 2024-0245
- 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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