Recurance · prevention of future deaths reports
Pre-inquest brief
Inappropriate triage coding delays mental health ambulance response
The earlier warning
Helen Sheath · 27 Jan 2020 · Emma Whitting, Bedfordshire and Luton
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier”
judiciary.uk/prevention-of-future-death-reports/helen-sheath
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 24 Oct 2024 · Aran Bradbury · Christopher Leach · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Helen Sheath · 27 Jan 2020
“If the first call had been coded as a Category 2, it seems likely that the RRV, Mental Health Street Triage Team (and even possibly the original DSA) would have arrived on scene much earlier”
Later · Aran Bradbury · 24 Oct 2024
“The evidence I heard at inquest was that the call was coded at 25-C-1, which was as a Category 3 call.”
What happened next
No web check of the stated actions has been published for this chain.