A coroner has warned the NHS there is a "risk of future deaths" after ambulance delays contributed to a North East man's death. Andrew Edward Watson died 67 minutes after calling 999 on October 10 2019, and by the time paramedics arrived to try to save him, "the cause was already lost".
As previously reported by Chronicle Live, an inquest at Crook Coroner's Court heard there had been "delays in the response of the ambulance service" which meant "emergency treatment [...] was not delivered in time". Andrew had been living in supported accommodation in Langley Moor.
Inquest findings
The 32-year-old had quinsy, a complication of tonsilitis which sees a swelling of the tonsils block the airways. The inquest concluded that Andrew died a natural death to which the delayed arrival of an ambulance contributed.
Senior assistant coroner Crispin Oliver was left "baffled" by the "perverse" situation which meant that because Andrew had called 999 himself, his choking symptoms could not generate a higher priority - category 1 - response. Due to his concerns regarding discrepancies in how cases are categorised by the pathway algorithm, the coroner wrote a prevention of future deaths report to NHS England in July.
Significant risk of future deaths
The report said: "In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action."
Setting out his matters of concerns, the coroner continued: "Andrew died on 10 October 2019 as a result of respiratory failure due to upper airway obstruction due to peri-tonsillar abscess. He called 999 himself.
"Delays in the arrival of the ambulance contributed to the death. The evidence from North East Ambulance Service (NEAS), was that he had been correctly triaged under the pathway algorithm to a category two response. I am concerned that, according to the evidence I heard in relation to the pathway algorithm, choking due to intrusion of a foreign object generates a category one response, whereas choking due to a preventable but equally life-threatening natural cause generates only a category two."
The evidence from NEAS was that because Andrew was making the call himself and that it was not made by a third party was material to categorization, therefore I am also concerned that simply because he self-helped that this somehow reflected in a lower categorization.
"Finally, I am also concerned that a clearly life threatening condition, albeit preventable with critical care intervention, which in the event proved fatal in this case, is treated as warranting a category two response rather than category one."
NEAS 'truly sorry'
In a statement following the conclusion of Andrew's inquest in July, Karen O'Brien, Deputy Chief Executive at North East Ambulance Service, said: "We are truly sorry for Andrew's death and the distress caused to his family. We did not respond as quickly as we should have when he called us, and we have always acknowledged that this delay likely contributed to his death.
"We have taken significant steps since 2019 to reduce the delays to ambulance responses, which has included substantial investment in more paramedics and more ambulances. Today, our service is performing more strongly and reaching people faster.
"The coroner highlighted flaws in our investigation and governance processes at that time which was extensively reported upon in 2023 and have been addressed with oversight from NHS England.
"This has been a profoundly tragic case which has had an impact on everyone involved. We hope the inquest has provided answers for the family, although we know it does not ease the pain of their loss."
The National Medical Director of NHS England was under a duty to respond to the coroner's report by September 18, 2026. The coroner may also extend the period if an appropriate application is made.
