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Jean Frickel · Prevention of Future Deaths report View report

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

Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

Gary William Million · Prevention of Future Deaths report View report

29 Jul 2014 County Durham and Darlington A. Tweddle

Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.

Margaret HUNTLEY · Prevention of Future Deaths report View report

13 Aug 2024 Teesside and Hartlepool P. Appleton

Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.

Ronald Hamer · Prevention of Future Deaths report View report

20 Apr 2016 South Wales Central G. Hughes

Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.

Kevan FUNNELL · Prevention of Future Deaths report View report

27 Feb 2018 Brighton and Hove V. Hamilton-Deeley

Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose in this case.

MAUREEN WHARTON · Prevention of Future Deaths report View report

6 Dec 2019 Gateshead and South Tyneside T. Carney

Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.

Edna May Wiggett · Prevention of Future Deaths report View report

18 Mar 2026 Norfolk R. Weyell

Edna May Wiggett fell at home and sustained a fractured hip, underwent surgery, and later died from heart failure following surgery. The report identified a failure to re-triage a second ambulance call reporting increased pain, leading to delays in dispatch and a prolonged wait on the floor, which more than minimally contributed to her death.

Grant Thomas Benson and Gordon Nicky Davidson · Prevention of Future Deaths report View report

18 Mar 2015 County Durham and Darlington A. Tweddle

Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.

Oliver Hall · Prevention of Future Deaths report View report

17 Jun 2019 Suffolk N. Parsley

Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.

Philip Richard Hayes · Prevention of Future Deaths report View report

30 Oct 2019 Newcastle upon Tyne K. Dilks

Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based triage.

Christopher John Smith · Prevention of Future Deaths report View report

28 Oct 2015 Manchester West S. Jones

Christopher John Smith died instantaneously after jumping from Barton Bridge on 15 July 2015. The principal concern was a 12-minute delay in contacting the ambulance service, caused by a communication breakdown about which service was responsible for making the call, although this did not affect the outcome in this case.

Anthony Slack · Prevention of Future Deaths report View report

1 Dec 2020 Manchester South A. Mutch

Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.

Pamela June Conway · Prevention of Future Deaths report View report

26 Aug 2016 North Wales (East and Central) J. Gittins

Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.

Lyn Mary BRIND · Prevention of Future Deaths report View report

18 Jan 2023 Norfolk J. Lake

Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.

Blaithin Grianne Buckley · Prevention of Future Deaths report View report

16 Sep 2019 Northamptonshire J. Devonish

Blaithin Grianne Buckley died at Northampton General Hospital on 30 April 2018 after being found hanging in a phone booth at St. Andrews Healthcare while on five-minute observations. Concerns included the delay in calling an ambulance and uncertainty about whether procedures adequately explained when an ambulance should be called. The inquest also identified failures relating to locking the phone booth, transferring relevant patient history, and the process for calling the ambulance service.

William VICKERS · Prevention of Future Deaths report View report

26 Jul 2019 Milton Keynes T. Osborne

William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

Roger Clive DUGGAN · Prevention of Future Deaths report View report

7 Apr 2014 Exeter & Greater Devon E. Earland

Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report View report

31 Jul 2014 Inner North London M. Hassell

Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.

James Paul Michael Masheter · Prevention of Future Deaths report View report

3 Apr 2025 Lancashire and Blackburn with Darwen K. Bisset

James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.

Keith Nielsen · Prevention of Future Deaths report View report

26 Jun 2023 Surrey A. Crawford

Keith Nielsen fell at home, sustained a head injury while taking Warfarin, and died in hospital on 23 March 2022. The concerns included the handling of his 999 call, including the no-send disposition despite his circumstances, and repeated operation of the ambulance service at Stage 4 of its Surge Management Plan, with demand exceeding available resources and responses not meeting target timeframes.