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Martin Keith Sullivan · Prevention of Future Deaths report View report

2 Mar 2021 Manchester South A. Bridgman

Martin Keith Sullivan, aged 15, died on 24 November 2019 after experiencing a severe asthma attack. He was prioritised as Category 2 during two 999 calls, and his father was not asked about taking him directly to hospital; ambulance delays followed before Martin was taken to hospital, where resuscitation was unsuccessful. Concerns included whether the MPDS algorithm and call-handler script recognised the severity of his symptoms, whether Category 2 response times could be met, and whether direct transport to hospital should have been discussed.

Wyllow-Raine Swinburn · Prevention of Future Deaths report View report

3 Feb 2024 Oxfordshire D. Salter

Wyllow-Raine Swinburn became unresponsive at home on 30 September 2022 after being discharged from hospital the previous evening, and died in hospital that day. The concerns related to a seven-minute delay in connecting the 999 call to an emergency call taker and the 31-minute response time for the first paramedic to attend.

Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report View report

30 Jul 2018 South Wales Central R. Knight

On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.

Andrew Michael Lewis · Prevention of Future Deaths report View report

19 Dec 2024 Berkshire H. Connor

Andrew Michael Lewis died at home on 7 May 2024 after calling 111 with weakness in his legs and an earlier fall. An ambulance arrived about 10 hours after his first call, although the call had been categorised as requiring attendance within two hours; the report states there was simply no ambulance available to send earlier. The inquest recorded the cause of death as acute on chronic gastrointestinal haemorrhage, bleeding oesophageal varices, alcoholic liver cirrhosis, and low volume subdural haemorrhage, with the conclusion of an alcohol-related death contributed to by head injury.

Mrs Withers · Prevention of Future Deaths report View report

12 Oct 2015 Northamptonshire H. Shah

Mrs Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at hospital.

Clive Harold Turner · Prevention of Future Deaths report View report

12 Sep 2014 North Wales (East and Central) J. Gittins

Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.

Ellen Lillian MacFarlane · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South A. Mutch

Ellen Lillian MacFarlane had an accidental fall at her care home and waited over five hours for an ambulance before being taken to hospital, where she was found to have a fractured neck of femur. She underwent surgery, subsequently deteriorated, and died at Tameside General Hospital. The concerns included delays in ambulance provision and difficulties obtaining cardiac tests at weekends, contributing to delays in deciding when to operate on fractured neck of femur patients.

Keith Hodson · Prevention of Future Deaths report View report

18 Apr 2023 Herefordshire H. Bricknell

Keith Hodson had a complex medical history, with delays before an ambulance was called, in ambulance attendance, on hospital admission and in receiving appropriate treatment. Concerns included failure to consistently use an appropriate triage system in Accident and Emergency, inadequate escalation and monitoring, insufficient senior oversight, delays in signing off serious incident reports, and untimely communication with the next of kin.

Olive JOHNSON · Prevention of Future Deaths report View report

24 Jan 2019 Lincolnshire P. Cooper

Olive JOHNSON died within 24 hours of admission to Pilgrim Hospital on 11 May 2018. The concerns raised relate to the absence of a first responder, emergency response times, how response delays were recorded after regrading, and whether EMAS had sufficient conveying resources to meet its targets.

Harry Peter DUNN · Prevention of Future Deaths report View report

4 Jul 2024 Northamptonshire A. Pember

Harry Peter Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raised concerns about the unavailability and delayed response of ambulance resources, including delays caused by lengthy hospital handovers, and the continuing risk of future deaths from these delays.

Vera SPENCER · Prevention of Future Deaths report View report

11 Nov 2024 Derby and Derbyshire S. Lomas

Vera Spencer fell at home and waited approximately 11 hours for an ambulance before being taken to hospital with a fractured hip and chest infection. Her condition deteriorated after surgery, and she died on 11 December 2023; the medical cause of death included pneumonia and a fall. The principal concern was that people who fall at home may wait many hours for paramedic attendance during periods of ambulance service pressure, with no local out-of-hours falls service to assist them off the floor.

Clive GOULD · Prevention of Future Deaths report View report

16 Dec 2013 Oxfordshire N. Graham

Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

Veronica Jenkins · Prevention of Future Deaths report View report

31 Mar 2023 Surrey A. Crawford

Veronica Jenkins, a 72-year-old woman with metastatic bowel cancer, developed sudden chest pain on 10 May 2022 and died in hospital on 11 May 2022 after suffering two cardiac arrests. The report identified a delayed ambulance response caused by a deficit in operational hours, with concerns that staff shortages and hospital handover delays could recur and compromise patient safety.

James CAMPION · Prevention of Future Deaths report View report

20 Dec 2023 Liverpool and the Wirral A. Bhardwaj

James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.

Charles Stephen Rothwell · Prevention of Future Deaths report View report

5 Oct 2022 Cheshire C. Welch

Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.

Mark Stephen Smith · Prevention of Future Deaths report View report

21 Oct 2013 North London A. Walker

Mark Stephen Smith died after intentionally taking an overdose of medication, complicated by ethanol use and underlying health conditions. An ambulance response was delayed, and the report states that this delay was likely to have contributed to his death. The substantive concern was whether clearer guidance and possible supervisor consultation were needed when deciding not to remain on the line with a person who had taken an intentional overdose and was alone.

Martin Daffydd Barker · Prevention of Future Deaths report View report

9 Sep 2013 Manchester South J. Kearsley

Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.

Tracey Ostler · Prevention of Future Deaths report View report

4 Aug 2025 Surrey C. Topping

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

Elizabeth Muriel Leah · Prevention of Future Deaths report View report

19 Feb 2015 Manchester South J. Pollard

Elizabeth Muriel Leah, an 87-year-old care home resident with severe dementia, fell on 2 July 2014 and broke her femur. Although an ambulance was called, staff were advised to take her to hospital by taxi because of an anticipated ambulance delay. The principal concerns were insufficient ambulance and staffing capacity, delays transferring patients into emergency departments, and hospital bed-blocking.

Raymond Gillespie · Prevention of Future Deaths report View report

25 May 2022 North Wales (East and Central) K. Sutherland

Raymond Gillespie, a care home resident with multiple comorbidities, suffered an unwitnessed fall on 8 October 2021 and waited almost 15 hours for a paramedic response after calls to the Welsh Ambulance Service Trust. The report identified delays caused by resource availability and ambulance handover delays, with a continuing risk of future deaths or harm while patients await transfer or community paramedic assistance.