Ambulance delay contributed to man's death - coroner

Action is needed after a "significant" ambulance delay contributed to a man's death, a coroner has warned.

Liam McCarlie took his own life on 1 April 2023, a coroner concluded in June.

The coroner also found months of insufficient plans to protect Mr McCarlie while he waited for an assessment.

East Midlands Ambulance Service (EMAS) and Northamptonshire Integrated Care Board (ICB) said they were working to identify learning opportunities.

Mr McCarlie's family contacted the ambulance service at 17:52 BST on 1 April after receiving text suicidal messages from him.

The call was allocated a 120 minute response time but paramedics did not arrive until 23:23, five hours and 19 minutes after the first call.

Two previous allocated ambulances were stood down and reallocated.

Assistant Northamptonshire coroner Jonathan Dixey said: "Had the ambulance service arrived within the required response time, it would have done so at a time when Mr McCarlie was still alive."

The last time anyone heard from him was at 20:18.

"This delay contributed to Mr McCarlie’s death," the coroner ruled.

His mental health had "deteriorated significantly" in February 2023 and by 15 February he was referred to be further assessed.

However, he had not been formally assessed by the time of his death.

"This possibly contributed to his death," the coroner said.

Mr Dixey raised concerns in a prevention of future deaths report that paramedics with the East Midlands Ambulance Service (EMAS) cannot access a patient's mental health records.

"Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources," he said.

Keeley Sheldon, Director of Quality Improvement and Patient Safety at East Midlands Ambulance Service, said: “We take matters of patient safety regarding delays and responsiveness of our service very seriously.

"We are reviewing the coroner’s report, and working with our partners, we will identify any areas of learning and implement any actions we can take.

A spokesperson for Northamptonshire Integrated Care Board said: "We are working closely with system partners across Northamptonshire to discuss the findings and will work together to assess and implement any actions that could be taken."

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