James Campion
20 Dec 2023 · Coroner Anita Bhardwaj · Liverpool and Wirral
This report repeats 3 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed triage of overdose call
“The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose”
2. delayed ambulance dispatch
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance”
3. lack of mental health practitioners in ambulance control rooms
“Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms”
Linked reports
Closely relatedConfidence 0.80 · moderate
Earlier report
“The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased's location”
This report
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”
Identical hazardConfidence 0.90 · high
Earlier report
“when they found Mr [name redacted] and rang for an ambulance they were told that due to the ongoing demands on the Ambulance Service that it would be approximately 6 hours before one could attend and transport Mr [name redacted] to hospital”
This report
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance”
Closely relatedConfidence 0.85 · high
Earlier report
“Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”
This report
“The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment and further psychiatric assistance.”
Closely relatedConfidence 0.90 · high
This report
“The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose.”
Later report
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”
Closely relatedConfidence 0.85 · high
This report
“The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr [name redacted] receiving medical treatment”
Later report
“The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed.”
Responses
2023-0539-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · March 2025
“care. The Department recognises the significant pressure the urgent and emergency care system is facing. That is why we published our Delivery plan for recovering urgent and emergency care services, which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across”