A North East mum has spoken of how her family has been forced to spend "years searching for the truth" after the death of her son Andrew Watson aged just 32. Andrew died in October 2019.
Inquest findings
Almost seven years on, a final inquest at Durham Coroners' Court in Crook has found that the Middlesbrough-raised man's death was "contributed to" by ambulance delays getting to him at his home in Langley Moor. There were delays in prioritising his case and then "high demand" meant the first paramedics on the scene didn't arrive until 67 minutes had passed.
Andrew's case saw the paramedics who attended and tried to save his life flag concerns that "something had gone wrong" - but an investigation under the direction of the North East Ambulance Service's then head of patient safety Shelley Dyson saw the level of harm ascribed to Andrew's case downgraded. Ms Dyson and her then-superior Joanne Baxter, who was a director at NEAS but has also since left, are both in the middle of tribunal proceedings.
Family's fight for truth
Documents pertaining to the investigation were never shared with his family and the coroner was only told in May 2020 - months after the coronial proceedings had been discontinued.
Now, following an inquest, Andrew's mum Liz said: "For almost seven years, our family has lived with the devastating loss of Andrew while also fighting for answers about the circumstances surrounding his death. Nothing can bring Andrew back. He was only 32 years old and had his whole life ahead of him.
"He was funny, intelligent, kind and full of life. Andrew brought warmth, laughter and energy wherever he went. He was deeply loved by his family and friends, and he is missed every single day.
"We are grateful that the inquest has finally been able to examine what happened and establish the facts surrounding Andrew’s death. It has been acknowledged by North East Ambulance Service that the delay in getting an ambulance to Andrew contributed to his death.
"We also acknowledge the apology that has now been offered to our family, which came after many years of unanswered questions and after we had to fight for this inquest to be reopened."
Whistleblower revelations
Andrew's case was one highlighted by whistleblowers at NEAS in 2022. It was in fact only after this and following media attention that his family were made aware of the concerns which existed.
The case was one of several whereby key documents either were not disclosed to a coroner or were disclosed with a significant delay. NEAS's previous chief executive Helen Ray acknowledged that there had been "historical failings" in processes and the organisation made a public apology.
An NHS England commissioned review presided over by Dame Marianne Griffiths - a former NHS chief executive who worked on the south coast of England - found that there had been issues including "leadership dysfunction" which led to these concerns.
Coroner's comments
At the inquest's conclusion, senior assistant coroner Crispin Oliver highlighted how he had heard testimony that evidence had been "manipulated" to fit a pre-ordained harm level.
Ms Watson added: "No family should have to spend years searching for the truth about how their loved one died. We hope this inquest helps ensure there is greater openness, accountability and learning so that other families are spared the pain we have experienced.
"Andrew deserved the chance to survive. We hope the lessons identified through this inquest, together with the changes the ambulance service says it has made, mean that others facing a medical emergency receive the care they need in time.
"We would like to thank everyone who has supported us throughout this long process, including our legal team and counsel, as well as the coroner for the careful consideration given to the evidence."
Legal response
Representing the family, Matthew Westlake from law firm Leigh Day added: "This has been a long and difficult journey for Andrew Watson’s family, who have waited almost seven years for a full examination of the circumstances surrounding his death.
"The evidence heard during the inquest established that there was a significant delay before an ambulance reached Andrew, and North East Ambulance Service has accepted that this delay contributed to his death. The Trust has now apologised to the family, and that acknowledgement is welcomed.
"No legal process can undo Andrew’s tragic death, but his family’s determination has ensured the circumstances have been fully examined and lessons can be learned. The family hope the findings of this inquest, together with the changes described by the ambulance service, will help prevent other families experiencing a similar tragedy."
Ambulance service apology
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."
