Northamptonshire: Ambulance delay contributed to man’s death

A coroner warned that action must be taken after a “significant” ambulance delay contributed to a man’s death.

Liam McCarlie took his own life on April 1, 2023, the coroner said in June.

The coroner also found that there had been inadequate plans in place to protect Mr McCarlie for months while he awaited an assessment.

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

Mr McCarlie’s family contacted emergency services at 5.52pm (CEST) on 1 April after receiving text messages from him expressing suicidal thoughts.

The emergency call was scheduled to take 120 minutes to respond, but paramedics did not arrive until 11:23 p.m., five hours and 19 minutes after the first emergency call.

Two previously assigned ambulances were taken out of service and reallocated.

Jonathan Dixey, deputy coroner for Northamptonshire, said: “Had the emergency services arrived within the required response time, they would have arrived at a time when Mr McCarlie was still alive.”

The last time anyone heard from him was at 8:18 p.m.

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

His mental health had “deteriorated significantly” in February 2023 and he was referred for further evaluation on February 15.

However, at the time of his death, he had not yet been officially assessed.

“This may have contributed to his death,” the coroner said.

Mr Dixey raised concerns in a report to prevent future deaths that paramedics from the East Midlands Ambulance Service (EMAS) do not have access to a patient’s psychiatric medical records.

“Such information may be relevant, for example, when it comes to whether the patient has had suicidal thoughts or attempts in the past. This information, in turn, may be important for triage and ambulance dispatch,” he said.

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

“We are reviewing the autopsy report and will work with our partners to identify potential learning areas and implement all measures at our disposal.

A spokesman for the Northamptonshire Integrated Care Board said: “We are working closely with system partners across Northamptonshire to discuss the findings and will jointly assess and implement all possible measures.”