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Miles Robinson · Prevention of Future Deaths report View report

8 Jul 2025 South London S. Reeves

Miles Robinson developed chest pains and vomiting on 19 December 2022 and experienced delays and incorrect triage after his granddaughter called 999. He travelled by Uber to an urgent treatment centre, where he suffered a cardiac arrest, and died at 06:36 after further cardiac arrests. The principal concerns were the incorrect categorisation of the 999 call and the rigidity of the triage system, alongside ambulance allocation and dispatch delays that may place patients reporting a heart attack at risk of death before an ambulance arrives.

Sandra Dianne Finch · Prevention of Future Deaths report View report

9 May 2023 Staffordshire South E. Serrano

Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 calls.

Fern Elisabeth Foster · Prevention of Future Deaths report View report

7 Jun 2024 Buckinghamshire C. Butler

Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.

Simon Boyd · Prevention of Future Deaths report View report

6 Nov 2024 Manchester South C. Morris

Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.

Mia Gibson · Prevention of Future Deaths report View report

11 May 2016 Nottinghamshire H. Connor

Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.

Anthony William McCormack · Prevention of Future Deaths report View report

4 Sep 2017 Manchester City F. Borrill

Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.

Irene Annie Davies · Prevention of Future Deaths report View report

14 Sep 2022 Manchester South A. Mutch

Irene Annie Davies had multiple underlying health issues, including congestive cardiac failure and an infected nephrostomy associated with renal stones. After an accidental fall at home on 1 March 2022, she waited more than an hour for a Category 2 ambulance response, was taken to hospital, and was found unresponsive there on 2 March 2022. The substantive concerns included delays to renal stone surgery and delays in ambulance attendance due to service capacity and availability issues.

Keith William Rushton · Prevention of Future Deaths report View report

13 Sep 2016 West Yorkshire (Western) M. Fleming

Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.

Rita Maureen TAYLOR · Prevention of Future Deaths report View report

25 Jan 2023 Milton Keynes T. Osborne

Rita Maureen TAYLOR suffered an unwitnessed fall at home and a head injury. Multiple ambulance calls were made, but an ambulance was delayed because no resources were available; she arrived at hospital with a Glasgow Coma Score of 3 and died the same day. The principal concern was insufficient ambulance service resources and the resulting delay, which the inquest conclusion described as causing lost opportunities to admit her and begin treatment.

Christopher Philip Fields · Prevention of Future Deaths report View report

18 May 2016 Manchester South J. Pollard

Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.

Andrew Collins · Prevention of Future Deaths report View report

2 Oct 2018 South Wales Central A. Barkley

Andrew Collins became acutely unwell at home on 6 June 2018 with a severe headache, was found to have a subdural haematoma, underwent emergency neurosurgery, and died on 16 June 2018. The report raised concern about a delay of approximately three hours in sending an ambulance despite his rapidly deteriorating condition, attributed to a lack of available resources.

Sabrina Stevenson · Prevention of Future Deaths report View report

30 Mar 2015 Inner North London R. Brittain

Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

Alyn Rees · Prevention of Future Deaths report View report

9 Sep 2020 Gwent C. Saunders

Alyn Rees became acutely unwell on 3 December 2019, experienced breathing difficulties, deteriorated into cardiac arrest, and died after paramedics were unable to revive him. Concerns were raised about the approximately two-hour wait for an emergency ambulance, the lack of advice about the expected arrival time, the absence of an indicated response time for an Amber 1 call, and delays transferring patients into hospital care that prevented ambulances from being released.

Leonard Charles Harmsworth · Prevention of Future Deaths report View report

20 Jun 2023 North Wales (East and Central) K. Sutherland

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

Richard Carpenter · Prevention of Future Deaths report View report

25 Apr 2024 Wiltshire and Swindon D. Ridley

Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.

DAVID LESLIE SELMAN · Prevention of Future Deaths report View report

1 Oct 2013 Oxfordshire N. Graham

David Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause of death.

Marjorie McMahon · Prevention of Future Deaths report View report

25 Jun 2018 Manchester South R. Galloway

Marjorie McMahon became increasingly unwell at Cherry Tree House and was taken to hospital on 7 March 2018, where she received treatment before dying on 8 March 2018. The principal concern was the delay in ambulance and paramedic attendance despite her being categorised as a level 2 priority, with an 8-minute guideline response time.

George Boulton · Prevention of Future Deaths report View report

7 Aug 2015 Leicester City and South Leicestershire L. Brown

George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

Graham James Sutton · Prevention of Future Deaths report View report

24 Feb 2014 North London A. Walker

On 10 July 2013, Graham James Sutton fell five feet from a ladder while cutting a hedge, struck his head on concrete, and later died after being taken to hospital and transferred to a Trauma Centre. The concern was that the London Ambulance Service did not automatically link the fall, his age over 50, and his use of the anti-clotting medication Clopidogrel to a response within eight minutes.

Roman Louie BARR · Prevention of Future Deaths report View report

4 Mar 2026 Coventry L. Lee

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.