Liam Martin Coleman · Prevention of Future Deaths report

On the 9th October 2012 I opened an inquest touching the death of Liam Martin Coleman, 57 years old. The investigation concluded at the end of the inquest on the 12th May 2014. The conclusion of the inquest was "Narrative", the medical case of death was 1a Acute Left Ventricular failure 1b Coronary and Hypertensive Heart Disease and Chronic Obstructive Pulmonary Disease 2 Morbid Obesity.

On the 3rd October 2012 Liam Martin Coleman at 2.25 hrs in the morning Liam Martin Coleman collapsed at his home. A call was put through to the London Ambulance Service at 2.49 hrs. A second call was put through to the London Ambulance Service at 03.00 hrs.
Following the second call a Fast Response Unit was dispatched arriving at 3.20 hrs with the crew at Mr Coleman's side by 3.22 hrs. An ambulance was dispatched at 3.18 hrs arriving at 3.28hrs with the crew at Mr Coleman's side by 3.29hrs. A further ambulance was dispatched when it became available at 3.44 hrs arriving at 3.49hrs with the crew at Mr Coleman's side by 03.49 hrs. London Ambulance Staff provided advanced life support until at 4.43 hrs when London Ambulance Staff confirmed that Mr Coleman had died.
Information from the London Ambulance Service at the inquest indicated that ambulance availability was around 75% of the planned hours including any unstaffed vehicles and vehicles that were out of service. The service average for the year 2012 to 2013 was 80%.
In these particular circumstances the delay did not, on the balance of probability, more than minimally or trivially contribute to Mr Coleman's death.

That there were insufficient ambulances available to cover the number of Red 1 and Red 2 calls in the early hours of the morning of the 3rd October 2012.