Yunus Hoque · Prevention of Future Deaths report

On the 22nd January 2024, an inquest was opened concerning the death of Yunus Hoque, aged 13 years at the time of death. The inquest was heard with a jury on the 9th February 2026 to the 12th of February 2026.

The jury found the medical cause of death to be:

1a) Multi-organ failure
1b) Group A Streptococcus bronchopneumonia and Sepsis

The jury returned a conclusion of natural causes contributed to by neglect.

On the 14th January 2024, Yunus Hoque became ill with a viral infection. Over the course of the following week he became increasingly unwell. A Group A streptococcal infection overlayed the viral infection. By the 18th January 2024, Yunus was struggling to lift his head from his pillow, he had a high temperature and he could not walk downstairs unaided. He was sleepy and ceased to eat. He continued to deteriorate. His mother called 111 at 22:42 hours on the 21st January 2024. The outcome of the assessment by North West Ambulance Service [‘NWAS’] in that call was that this was a Category 2 response. Category 2 had an average response time of 18 minutes. His mother was informed there would be an ambulance in about an hour. By 00:52 no ambulance had attended, by which time Yunus was having a seizure. His mother called 999 and on assessment during that call, this was now a Category 1 response. The average response time for Category 1 was 7 minutes. An ambulance was allocated at 00:56 hours and arrived at Yunus’s home at 01:01 hours. Yunus arrived at Tameside General Hospital at 01:20 hours, by which time he was in respiratory arrest. He went into cardiac arrest at the hospital. There was no response to repeated attempts at resuscitation. Death was certified at 02:53 hours.

1. The target response time for a Category 2 response was 18 minutes. The caller was told that an ambulance would be with Yunus in about an hour.

2. A period of approximately 2 hours elapsed during which no ambulance arrived, and before the caller, Yunus’s mother, called 999. During this period, no communication was received by the caller from NWAS, or on their behalf, to inform her that there would be this unforeseen delay.

3. During this 2 hour period, Yunus’s condition deteriorated further, moving from Category 2 to Category 1.

4. No further calls had been made by Yunus’s mother during this period because it was her understanding that an ambulance would be with Yunus within the period of time indicated in the first call. Therefore she waited.

5. The evidence at the inquest established that the categorization in each call was at the appropriate level.

6. However, it is apparent that in circumstances where there is a significant delay over and above that indicated to the caller, there is no follow-up call or communication to indicate further delay, to confirm the status of the patient, or to suggest that alternative transport is required, if possible. Notwithstanding this, in a changing situation, a patient may deteriorate, moving from Category 2 to Category 1 and therefore requiring a more urgent response: as was apparent from the evidence at this inquest. But a patient, family member and / or carer who relies upon information already provided by the call handler, may continue to wait for an ambulance that they have been told will arrive in a given period of time, when in reality there is no likelihood of that ambulance arriving. At the same time, NWAS will be proceeding on the basis that they are dealing with a Category 2 when the case has now become a Category 1.

7. The evidence established that Yunus was so ill by the time of the first call to 111 at 22:42 on 21st January 2024, that the delay in the arrival of an ambulance did not contribute to his death.

8. Nevertheless, the absence of any system for a follow-up call by or on behalf of NWAS in circumstances where an unforeseen delay in ambulance attendance is going to be far in excess of that indicated to the caller, creates a risk that further deaths could occur, given that during this period a patient may deteriorate and their categorization can move to Category 1 from a lower category.