Derek Burt
16 Jun 2026 · Coroner Karen Taylor · West Sussex, Brighton and Hove
The coroner's concerns
1. delayed emergency response
“The call was not connected to an operator for a further five minutes and 49 seconds meaning the time was roughly 22:42”
2. lack of guidance for careline operators handling third party emergencies
“Appello does not have any specific documentation, training material or guidance that considers calls for assistance made by the service user for people other than themselves”
3. missing critical information in emergency communication
“the first careline operator did not pass on a key piece of information to the EMA, namely that the caller did not have access to a phone”
4. failure to escalate urgent clinical situation
“the first careline operator did not call the EMA back when she learned Mr [name redacted] was non responsive and had developed breathing problems”
5. inadequate note taking and information capture in emergency dispatch
“the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I”
6. lack of coordinated AI improvement across emergency and careline services
“SECAMB is taking part in a pilot called Tortoise looking at using AI to improve the accuracy of note taking. It was unclear whether a similar scheme is being explored by careline companies”