Delayed ambulance dispatch to unconscious head injury patient
East Midlands Ambulance Service received 2 coroners' reports about this hazard between 22 Sept 2015 and 24 Jan 2019.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Significant and unacceptable delays occurred in despatching an ambulance to a patient who was unconscious and had clearly suffered a serious head Injury.”
Original on judiciary.uk ↗ East Midlands Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“Service has made significant investment in both staff and vehicle resources since 2014 in both "frontline" staff who attend 999 calls but also in staffing within the emergency operations centre. This recruitment has been supported with investment in our education centres to facilitate training from Emergency Care Assistant, through Ambulance Technician and ultimately to Paramedic level. Staff work on allocated rota lines with a percentage (around 12% in Lincolnshire) working on relief where they can be”
Stated timescale: March 2016
- 3 years 4 months laterClosely relatedConfidence 0.85 · higha different coroner
“Why were no first responder's called out in relation to the deceased?”
Original on judiciary.uk ↗ East Midlands Ambulance Service responded, stating 1 specific action.Response (PDF) ↗
“the Trust takes all matters relating to patient safety extremely seriously. In particular, matters arising from Coroners' Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed by the Incident Review Group and Lessons Learned Group.”
- All reports to East Midlands Ambulance Service
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2019Olive Johnson3 years 4 months after Stuart Knight · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with timely ambulance response leading to potential harm. The earlier report cites dispatch delays for an unconscious head‑injury patient; the later report questions why no first responders were dispatched at all.
Stuart Knight · 22 Sept 2015
“Significant and unacceptable delays occurred in despatching an ambulance to a patient who was unconscious and had clearly suffered a serious head Injury.”
Original on judiciary.uk ↗ Olive Johnson · 24 Jan 2019
“Why were no first responder's called out in relation to the deceased?”
Original on judiciary.uk ↗
Stated action · timescale: March 2016
“Service has made significant investment in both staff and vehicle resources since 2014 in both "frontline" staff who attend 999 calls but also in staffing within the emergency operations centre. This recruitment has been supported with investment in our education centres to facilitate training from Emergency Care Assistant, through Ambulance Technician and ultimately to Paramedic level. Staff work on allocated rota lines with a percentage (around 12% in Lincolnshire) working on relief where they can be”
Stated action
“the Trust takes all matters relating to patient safety extremely seriously. In particular, matters arising from Coroners' Inquests from which lessons can be learnt, including Prevention of Future Death Reports, are discussed by the Incident Review Group and Lessons Learned Group.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to East Midlands Ambulance Service at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2019 | 0.66 | 0.09 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for East Midlands Ambulance Service
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.