Family Welcomes Coroner’s Conclusion After Years Seeking Answers
The family of Peter Coates has expressed relief following a coroner’s ruling that ambulance delays possibly contributed to his death in 2019. They had endured years of distress while seeking clarity on the circumstances surrounding his final moments.
Peter Coates’s family reported encountering “delays and resistance” from the regional ambulance service during their efforts to understand what happened in the critical minutes before his passing.
Kellie Coates, daughter of Peter, stated:
“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.”
Details of the Incident and Inquest Findings
Coates, aged 62, died in the early hours of 14 March 2019 after a power outage caused the failure of mains-operated breathing equipment he relied on at home.
During the inquest, it was revealed that Coates, from Redcar, called 999 and an ambulance was dispatched by the North East Ambulance Service (NEAS). However, the same power cut prevented the emergency vehicle from passing through the electric gates at the ambulance station.
A second ambulance en route to the call stopped to refuel despite having nearly half a tank of fuel. Upon arrival, paramedics experienced delays locating the key safe to enter Coates’s home, even though he had provided the necessary access information during his emergency call.
In a narrative conclusion issued on Friday, Coroner Paul Appleton stated that ambulance delays had “possibly” contributed to Coates’s death.
The incident was classified as a category two ambulance call, which is the second-highest priority, because Coates was able to communicate. The target response time for category two calls is 90% within 40 minutes, while category one calls have a 90% target within 15 minutes.
Coroner Appleton indicated he would submit a prevention of future deaths report to the NHS, highlighting concerns about the gap between category one and two classifications, noting that “patients who require an immediate response but who are not in cardiac or respiratory arrest” cannot be categorized as category one.
Medical Background and Equipment Challenges
Coates had worked at Redcar British Steel throughout his career. He had developed lung cancer and, although it went into remission, he never fully recovered. He was later diagnosed with chronic obstructive pulmonary disease (COPD) and depended on a CPAP machine in his bedroom along with portable oxygen bottles to assist his breathing.
The inquest heard that after the power cut on 14 March 2019, Coates was unable to access his portable oxygen. An audio recording of his 999 call was played in court, during which Coates said:
“I’m breathing, but only just. You’d better get someone quick.”
Although Coates lived close to the ambulance station, the automatic gates would not open due to the power outage, and station staff were unaware of how to manually override them.
Paul Elstob, a member of the NEAS operational leadership team, told the inquest in January that ambulance staff have since been provided with instructions on manually operating the gate controls.
Response Delays and Final Outcome
The second ambulance dispatched to Coates’s residence came from a more distant station. Despite having nearly half a tank of fuel, the crew was permitted to stop at a petrol station en route, taking four minutes to refuel. Fuel was the only item purchased during this stop.
Paramedics were able to enter Coates’s home 47 minutes after his initial call for help, by which time he had already died.
Coates’s family only learned the full details of the circumstances surrounding his death three years later when a whistleblower provided a dossier revealing that the ambulance service had attempted to conceal its shortcomings.
Ambulance Service Response
Karen O’Brien, deputy chief executive at NEAS, acknowledged the incident’s tragic nature and its impact on both the family and staff involved. She stated:
“This is a tragic incident which we understand has deeply affected the family and those staff at NEAS who were involved. We are truly sorry that we were not quicker in responding to Mr Coates’ call.
We recognise that the time it’s taken to reach this conclusion has impacted Mr Coates’s loved ones and we wish to once again pass on our sincere condolences to his family for their very sad loss.”
