Ricky O'Connell · Prevention of Future Deaths report

On 3rd February 2025 I commenced an investigation into the death of Ricky O'CONNELL .The investigation concluded on the 2nd July 2025 and the conclusion was one of narrative: Died from acute myocardial ischaemia in the context of a significant delay in an ambulance attending following a 999 call. The medical cause of death was 1a) Acute Myocardial Ischaemia 1b) Coronary Atherosclerosis

Ricky O'Connell's partner called for an ambulance at 05:44 when his overnight symptoms deteriorated and he was concerned he was having a heart attack. He was categorised as a category 2 call. On the Department of Health Standards that should result in an ambulance on average arriving within 18 minutes and in 9 out of 10 cases within 40 minutes. The ambulance had not arrived by 06:38 due to very significant delays across the North West, primarily due to prolonged hospital handovers and overall demand on the service. His partner called again. At 06:43 during that call he collapsed and the call was upgraded to a Category 1. An Ambulance was dispatched (the earlier call was still in the queue for dispatch). CPR was given by his family and then the ambulance and he was transported to Tameside General Hospital where attempts to resuscitate him continued. He died at Tameside General Hospital on 27th January 2025.

1. The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed. The evidence given was that NWAS had done a huge amount of work to try to improve ambulance response times. This included improved staffing and call handling. However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr O’Connell.

2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services. The reasons for the demand were multi factorial and included challenges in accessing primary care.

3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further. On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances. This led to significant challenges for NWAS.

4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North West.