John Taylor

“The attending paramedics had not adequately checked the door handle. It was unlocked. As a result, they waited an extra 30 minutes for the police to arrive in order to gain entry.”

“The circumstances surrounding the failure to adequately check the door handle was not offered or elicited within the internal investigation. Subsequently it was not reported to the SI author. This issue was not considered within the SI.”

“Consideration was not given to the possibility of sending a taxi to Mr [name redacted] so he might be conveyed to hospital quickly.”