Paul Burke
2 May 2025 · Coroner Jacques Howell · Hertfordshire
This report repeats 5 earlier warnings. See the linked reports.
The coroner's concerns
1. delay in ambulance response
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care”
Linked reports
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”
This report
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”
Identical hazardConfidence 0.90 · 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
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”
Closely relatedConfidence 0.90 · high
Earlier report
“The delay in triaging the call made by Mr [name redacted] threatening to take an overdose resulted in him taking the overdose.”
This report
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”
Closely relatedConfidence 0.90 · high
Earlier report
“The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”
This report
“Delay in ambulance response and the consequent delay in the provision of pre- hospital emergency care.”
Identical hazardConfidence 0.90 · high
Earlier report
“The ambulance service was called at 0348 on 4 November 2022 and the call was coded as a Category 2 call requiring a response within 40 minutes. The ambulance finally arrived at 0542 on 4 November 2022, 1 hour and 56 minutes after the call.”
This report
“Despite the urgency with which an ambulance was required for Mr [name redacted] no ambulance resource was available.”