John Robert Taylor · Prevention of Future Deaths report

On 29 July 2022 I commenced an investigation into the death of John Robert TAYLOR aged 35. The investigation concluded at the end of the inquest on 07 December 2023. The conclusion of the inquest was that:

John Robert Taylor took a deliberate overdose of insulin, probably on 18.07.2022, with the intention of ending his life. He contacted the emergency services for help. The ambulance arrived the following morning. There was a delay of over 13 hours in the arrival of the ambulance. John was transported to the University Hospital of North Tees. He died at the University Hospital of North Tees on 27.07.2022. John’s death was contributed to by the delay in the arrival of the ambulance

The Medical Cause of his death is:
1a. Aspiration Pneumonia
1b. Hypoglycaemic Brain injury
1c. Insulin Overdose
II Morbid Obesity, Asthma, Ischaemic Heart Disease

Mr Taylor contacted the fire brigade’s boyfriend service on 18.07.22 expressing suicidal intent and plans. The fire brigade contacted Cleveland police who is turn contacted NEAS at 1557 on that day. After 3 unsuccessful attempts to speak with Mr Taylor, contact was made at 1610 by a call handler. The matter was assessed as requiring a Category 3 response. The ambulance arrived at Mr Taylor’s home at 0523 on 19.07.22, occasioning a delay of over 13 hours. The paramedic tried the door, but access could not be gained. At 0543 a request was to the police to gain entry. The police arrived on scene at 0558. When the police arrived, they noted that the door was unlocked and that the ambulances hadn’t tried the handle. They gained access to the property within one minute.
Care and attention were provided to Mr Taylor, and he was transported to UHNT. He died on 27.07.22.

I instructed an independent expert who determined that the delay in the ambulance arrival contributed to Mr Taylor’s death.
NEAS undertook an SI report. Oral evidence was provided by a Team Leader and a Clinical Section Manager, the latter having authored the SI Report. It was clear that a comprehensive investigation had been undertaken and learning implemented.
The author of the SI report was not aware that the door to the property was unlocked, and that access could have been gained over thirty minutes earlier.
My concern is that this information has not been offered or elicited nor has it been reported to the SI author. This issue has therefore not been considered within the SI.
A further concern is that the Family gave evidence about NEAS previously using a taxi to transport Mr Taylor to hospital on several occasions. The Clinical Section Manager said there was no policy on this and that it is in the operator’s “gift”. She told me there is no evidence that this option was considered on 18-19 July 2022 to transport him to hospital sooner.

1. The attending paramedics had not adequately checked the door handle. It was unlocked. As a result, they waited an extra 30 minutes for the police to arrive in order to gain entry.
2. The circumstances surrounding the failure to adequately check the door handle was not offered or elicited within the internal investigation. Subsequently it was not reported to the SI author. This issue was not considered within the SI.
3. Consideration was not given to the possibility of sending a taxi to Mr Taylor so he might be conveyed to hospital quickly.