Coroner's Findings Highlight Ambulance Delays in Peter Coates' Death

Peter Coates, a 62-year-old resident of Redcar, died on March 14, 2019, after a power cut disrupted the operation of his breathing equipment. Coates, who had a history of lung cancer and chronic obstructive pulmonary disease (COPD), called 999 for assistance. The North East Ambulance Service (NEAS) dispatched an ambulance, but a series of delays, including a malfunctioning automatic gate and a refueling stop, hindered the response. The coroner's inquest revealed that it took 47 minutes for paramedics to reach Coates after his call, during which time he succumbed to his condition.

The Guardian

Coroner Paul Appleton concluded that ambulance delays "possibly" contributed to Coates's death. He noted that the incident was classified as a category two call, which has a target response time of 40 minutes. Appleton expressed concern over the categorization system, indicating that patients requiring urgent assistance but not in immediate life-threatening situations may fall through the cracks. He plans to send a report to NHS England to address these gaps in emergency response protocols.

The Guardian

The Coates family has expressed relief at the coroner's findings, stating that they have faced "years of distress trying to pursue answers." Kellie Coates, Peter's daughter, criticized the ambulance service for prioritizing self-protection over accountability. She emphasized the need for systemic change, stating, “This process for us has not just been about managing grief; it has been about challenging a system that seems to be more focused on protecting itself than it is on acknowledging and learning from mistakes in its processes.”

The Guardian

The inquest revealed several operational failures within NEAS. The automatic gates at the ambulance station, which were inoperative due to the power cut, delayed the first ambulance's response. Additionally, the second ambulance, dispatched from a farther station, stopped to refuel despite having sufficient fuel. NEAS operational leadership acknowledged these issues, stating that staff have since been trained on how to manually operate the gate controls to prevent similar incidents in the future.

The Guardian

Karen O’Brien, deputy chief executive at NEAS, expressed condolences to Coates's family and acknowledged the tragic nature of the incident. She stated, “We are truly sorry that we were not quicker in responding to Mr. Coates’ call,” and emphasized that the service has made changes to improve response times.

The Guardian

While the coroner's findings indicate systemic issues within NEAS, the family only learned of the full circumstances surrounding Coates's death through a whistleblower's dossier three years later. This raises questions about transparency and accountability within the ambulance service.

The Guardian

• “She said: “This is a tragic incident which we understand has deeply affected the family and those staff at NEAS who were involved.” — Karen O’Brien, NEAS Deputy Chief Executive.

The Guardian