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Coroner’s reportPrevention of future deaths · 2025-0091

“There is insufficient Ambulance Service availability/resource to enable Ambulances to…”

Dated 17 Feb 2025, from the coroner for Teesside and Hartlepool. Sent to 3 organisations or people.

A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.

Read the full report on judiciary.uk

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The 56-day response deadline

All responses published

Replies were due by 14 Apr 2025.

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.

  1. Report dated17 Feb 2025
  2. Deadline14 Apr 2025
  3. Published on judiciary.uk20 Feb 2025
  4. Today23 Oct 2026

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Responses from each recipient

Responses from each recipient
Sent toResponse
Department of Health and Social CareNamed in the report as “DEPARTMENT OF HEALTH”Response publishedPublished on judiciary.uk in February 2025.
NHS EnglandNamed in the report as “NHS ENGLAND”Response publishedPublished on judiciary.uk in February 2025.
NHS North East and North Cumbria Integrated Care BoardNamed in the report as “NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD”Response publishedPublished on judiciary.uk in February 2025.

The coroner’s concerns

1. There is insufficient Ambulance Service availability/resource to enable Ambulances to attend to patients in a timely manner and in accordance with relevant target attendance times. 2. There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff. This document was classified as: OFFICIAL

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, 2025-0091
Added to Minute Book
8 Oct 2026
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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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