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recurance

Yunus Hoque

26 Feb 2026 · Coroner Benjamin Myers · Manchester South

The coroner's concerns

  1. 1. delayed ambulance arrival

    “The target response time for a Category 2 response was 18 minutes. The caller was told that an ambulance would be with [the deceased] in about an hour.”
  2. 2. lack of communication about delay

    “A period of approximately 2 hours elapsed during which no ambulance arrived, and before the caller, [the deceased]'s mother, called 999. During this period, no communication was received by the caller from NWAS, or on their behalf, to inform her that there would be this unforeseen delay.”
  3. 3. patient condition deterioration

    “During this 2 hour period, [the deceased]'s condition deteriorated further, moving from Category 2 to Category 1.”
  4. 4. systemic failure to follow up

    “the absence of any system for a follow-up call by or on behalf of NWAS in circumstances where an unforeseen delay in ambulance attendance is going to be far in excess of that indicated to the caller, creates a risk that further deaths could occur, given that during this period a patient may deteriorate and their categorization can move to Category 1 from a lower category.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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