John Taylor

Strictly Private and Confidential  
Ms Claire Bailey 
Senior Coroner 
His Majesty's Coroner for Teesside  
The Coroner's Service 
Middlesbrough Town Hall 
Albert Road 
Middlesbrough 
TS1 2QJ 

Date: 9 February 2024  

Ambulance Headquarters 
Bernicia House 
The Waterfront 
Goldcrest Way 
Newburn Riverside 
Newcastle upon Tyne 
NE15 8NY 

Dear Ms Bailey, 

Inquest into the death of John Robert Taylor 

Regulation 28 – Report to prevent future deaths  

I am writing in my role as Chief Executive of North East Ambulance Service NHS Foundation 
Trust ("NEAS") and in response to the Regulation 28 report for the prevention of future deaths 
dated 15 December 2023 as issued by you following the inquest into the tragic death of John 
Robert Taylor.   

The matters of concern listed in your report are: - 

1.  The  attending  paramedics  had  not  adequately  checked  the  door  handle.  It  was 
unlocked. As a result, they waited an extra 30 minutes for the police to arrive in 
order to gain entry. 

2.  The circumstances surrounding the failure to adequately check the door handle was not 
offered  or  elicited  within  the  internal  investigation.  Subsequently  it  was  not 
reported to the SI author. This issue was not considered within the SI. 

3.  Consideration was not given to the possibility of sending a taxi to Mr Taylor so he might 

be conveyed to hospital quickly. 

We were disappointed to have received a Regulation 28 report in relation to this inquest.  Two 
management  witnesses  from  NEAS  attended  the  inquest  and  provided  verbal  evidence 
alongside the documentary evidence previously disclosed. Evidence was introduced during the 
inquest which NEAS had no prior knowledge of, specifically in respect to the Police log and the 
previous use of taxis for Mr Taylor. NEAS did not have Properly Interested Person status at the 
inquest nor received the evidence bundle from other organisations. Had we understood your 
concerns we would have applied for Properly Interested Person status and would have been 
able to provide further evidence and an appropriate management witness statement to address 
the concerns in advance of the inquest. 

The North East Ambulance Service NHS Foundation Trust is registered, and therefore 
licensed to provide services, by the Care Quality Commission (Provider ID: RX601). 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We will address each point you have raised in your matters of concern below: - 

1.  The  attending  paramedics  had  not  adequately  checked  the  door  handle.  It  was 
unlocked. As a result, they waited an extra 30 minutes for the police to arrive in 
order to gain entry. 

Since learning this information during the inquest, we have received disclosure of the 
Police STORM Log and made enquiries with Cleveland Police colleagues. In addition, 
we have spoken with the attending NEAS crews and obtained a further account knowing 
the information disclosed.  

Cleveland Police colleagues have spoken with the Officers who attended the scene in 
July 2022. The feedback provided is that one of the Officers went to try the door whilst 
his  colleagues  retrieved  the  method  of  entry  equipment  from  the  police  vehicle.  The 
Officer trying the door has confirmed the door was unlocked and did not require forcible 
entry.  This is supported  by  the  second  Officer who  has  responded  to  the  query even 
though they have left the force. Our inquiries have not found any contact with NEAS to 
raise concerns following the incident nor raised with the attending NEAS crew. 

In respect to enquires made since the inquest, we have reviewed the call made to the 
NEAS Emergency Operations Centre by the attending crew. The call is very clear with 
a member of the crew clearly explaining the efforts made, including checking the door, 
knocking  on  windows/door and  shouting  though  the  letter box,  which  were  consistent 
with the written witness statement. One of my senior leadership team has met the crew 
and  raised  the  matter  in  respect  to  the  information  provided  by  the  police.  The 
recollection of events from the crew is consistent with their witness statements with both 
crew  members  stating  they  had  tried  to  open  the  door.  This  accords  with  the  details 
passed  during  the  conversation  with  the  NEAS  Emergency  Operations  Centre.  Upon 
speaking with the individual crew members, they both advised that on arrival of the police 
officers they gathered their equipment and just heard a comment from the police officers 
stating the “door was now open”. At this stage the crew immediately entered the property 
to assess and treat the patient.  

The crew have advised that at no stage did the attending police officers advise the door 
was unlocked nor did they make any complaint to the crew.  

It is not possible to fully explain what happened on scene, on balance it does however 
appear to be a misunderstanding by the NEAS crew, in so far as the comment the “door 
is open” meant the door was already open and did not require the police to gain entry by 
force.. This has been picked up with the NEAS crew and feedback provided that the door 
was unlocked and that every effort should be made before calling for assistance. I will 
go onto provide details of the wider improvements made in this respect.  

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 Whilst  not  directly  linked  with  this  case,  the  Trust  have  continued  to  work  with  other 
emergency  service  colleagues  in  respect  to  gaining  entry.  We  have  an  established 
Memorandum of Understanding (MOU) in place with Northumbria Police, Tyne and Wear 
Fire and Rescue and Northumberland Fire and Rescue Services. The MOU specifically 
covers forcible entry and has proven very successful since its inception in 2016. Efforts 
have continued to extend the MOU into County Durham and Darlington and Cleveland 
but further work is required as partners are not currently able to commit. I can however 
assure  that  this  remains  a  point  for  discussion  and  has  been  escalated  with  senior 
colleagues in those organisations. NEAS are not able to mandate this arrangement but 
continue to advocate the positive impact the MOU has made in other parts of the region.  

In addition to the ongoing efforts to extend the MOU, the Trust have recently, October 
2022, provided refresher training to managers within the Emergency Operations Centre 
(EOC) to ensure that their teams/staff follow the agreed process for cases where forcible 
entry may be required. This includes the arrangements in place via the MOU and also 
those areas were the primary support for forcible entry remains with the police. This is 
certainly the case within Cleveland. I have enclosed a copy of the current version of the 
MOU for your information, albeit this is not currently within the Cleveland area however 
the same principles for checking doors, windows and neighbours remain the same for 
our attending crews in the Cleveland area. There is an update currently being applied to 
the  MOU  detailing  the  improvements  to  the  process  which  is  proceeding  through  the 
ratification process.  

The  refresher  training  provided  to  the  EOC  managers  ensures  that  they  have  overall 
oversight of all cases in which a forcible entry request is being made. The improvements 
ensure  that  the  EOC  supervision  can  ensure  that  operational  staff  have  made  all 
reasonable efforts to gain entry to the property prior to the request for police or fire and 
rescue services to force entry. There are some exceptions to this process, such as in 
the case of a Category 1 response where it is clear from the outset of the call that forcible 
entry will be required, it will be requested by Health Advisors. 

NEAS  currently  has  several  methods  of  communication  in  relation  to  updates  and 
changes  to  practice  depending  on  the  service  line.  Operational  alerts  are  used  to 
communicate with operational teams, supported by internal communication platforms. 
EOC staff are provided with training bulletins, guidance notes and memos, whilst also 
being supported by the same communication platforms.  

I  have  enclosed  a  copy  of  the  updated  Standard  Operating  Procedures  (SOPS)  for 
Unscheduled Care Dispatch Staff. The overarching SOPS include an update in relation 
to forcible entry at pages 83 and 84, plus show the wider processes for completeness. 
The updated SOPS were  cascaded on 4 February 2024. In addition to the SOPS, an 
Operational Alert has been  issued  to operational staff, I  have  enclosed a  copy  of the 
alert  which  was  cascaded on 7  February 2024.  In  addition  updated  guidance  for Call 
Handling staff was shared on 8 February 2024 which I have enclosed.  

In  respect  to  wider collaboration  with  emergency  service  colleagues,  members of  the 
Trusts management team host and chair the Regional  Joint Partnership Management 
Group (JPMG), which consists of senior representatives from the regions 3 Police forces 
and the 4 Fire and Rescue Services. We have enclosed the terms of reference for this 
group which will assist with understanding the purpose and matters which are discussed. 
One of the standing agenda items, relates to any matters which require raising for the 
attention of any service.  

3 

 
 
 
 This  would  include  concerns/issues  such  as  those  associated  with  forcible  entry.    In 
addition, NEAS also chairs a multi-agency control managers meeting, with membership 
including control managers from each service. A similar standing agenda item in relation 
to matters for attention is also included in that group.  

In respect to the escalation/sharing of issues between partners this will be discussed at 
the JPMG meeting on Monday 12 February 2024. The chairperson of the meeting was 
in attendance at the inquest and spoke with the NEAS crew as well as liaising with a 
colleague  to  contact  Cleveland  Police  for their  Officers  recollections.  The  process  for 
escalation/sharing issues will be discussed using this case as an example to reinforce 
the importance of escalation and sharing any issues and/or learning. In addition to this 
agenda item, we have added the updated draft MOU for consideration by the partners. 
This is currently focused on those organisations linked with the current MOU, however 
it is hoped that it may help push the wider adoption of the MOU in Cleveland and County 
Durham 

2.  The circumstances surrounding the failure to adequately check the door handle 
was not offered or elicited within the internal investigation. Subsequently it was 
not reported to the SI author. This issue was not considered within the SI. 

The information contained within the Police STORM Log was not previously disclosed 
or shared with the Trust and therefore the investigating officer did not consider this matter 
within  the  serious  incident  investigation  report.  Statements  were  provided  by  the 
attending  NEAS  crew  which  covered  efforts  to  gain  entry  and  consider  the  delay  in 
gaining entry as per the request from your Officer. The witness statements provided did 
not mention that the attending Police Officers had found the door to be unlocked nor did 
Cleveland  Police  raise  the  matter  with  the  Trust.    Had  the  Investigating  Officer  and 
indeed other colleagues known this information then further enquiries would have been 
made during the investigation, whilst requesting witness statements from the attending 
crews.  

As mentioned above, we intended to reiterate the importance of raising/sharing issues 
between  partners  to  ensure  we  continue  to  learn  and  improve  from  any  issues.  It  is 
essential that we understand any challenges faced by our crews so we can learn lessons 
and review processes and considerations such as training, communication and related 
matters. 

3.  Consideration was not given to the possibility of sending a taxi to Mr Taylor so he 

might be conveyed to hospital quickly. 

Further  to  the  comments  made  by  the  family  during  the  inquest  and  the  subsequent 
concerns you have raised. We have undertaken a review of the calls received from Mr 
Taylor between 1 April 2021 and 19 July 2022, between these dates we received a total 
of  fifteen  111/999  calls.  The  records  show  that  on  one  occasion  a  taxi  was  used  for 
transportation albeit, this was an urgent booking made via the patients GP who advised 
of  the  appropriate  transportation.  The  below  is  a  summary  of  those  calls  and  the 
resources allocated as a response.  

16/04/21 – 111 call was made by the patient which was triaged with advice to make 
their own way to Hartlepool Urgent Care Centre. 

4 

 
 
 
 19/04/21 - Urgent case booked by GP advising transportation via Patient Transport 
Service (PTS) is suitable. A double crewed PTS resource transported the patient to 
North Tees Assessment Unit from the home address. 

30/04/21 -111 call was made by the patient which was triaged with advice to make 
their own way to Hartlepool Urgent Care Centre. 

30/04/21 - Urgent case booked by GP for patient with, chronic pancreatitis, advising 
transportation via Patient Transport Service (PTS) is suitable. A taxi was requested 
and transported the patient to North Tees Assessment Unit from the home 
address. 

30/04/21 - 999 call made by the patient which was triaged as a Category 1 
emergency ambulance response. Two double crewed emergency ambulances 
attended scene, remaining with the patient for one hour before leaving the patient 
at home with advice.  

01/05/21 – linked with above call, 999 from Cleveland Police to advise that they are 
not travelling.  

02/05/21 - 999 was made by the patient which was triaged as a Category 3 
emergency ambulance response. Call is upgraded to a Category 2 emergency 
ambulance response after a clinician call.  A double crewed emergency ambulance 
attended and transported the patient to North Tees Hospital. 

05/05/21 - 999 call received from a nurse which was triaged as a Category 2 
emergency  ambulance  response.  A  double  crewed  emergency  ambulance 
response attended and transported the patient to North Tees Hospital. 

28/07/21 - 999 call received from a GP which resulted in a Category 2 emergency 
ambulance response. A double crewed emergency ambulance arrived on scene, 
treating the patient on scene without onward transportation.   

10/08/21 - 999 call was made by a relative, from a different address, which was 
triaged as a Category 1 emergency ambulance response. One double crewed 
emergency ambulance and a support vehicle attended treating the patient before 
leaving at scene.   

31/08/21 - 999 call was made by the patient which was triaged to a Category 2 
emergency ambulance response. A doubled crewed emergency  ambulance 
attended and transported the patient to North Tees Hospital. 

01/11/21 - 999 call was made by the patient which was triaged as a Category 2 
emergency  ambulance  response.  A  double  crewed  emergency  ambulance 
attended and transported the patient to North Tees Hospital. 

04/03/22 - 999 call received from a GP which resulted in a Category 2 emergency 
ambulance response. A doubled crewed emergency ambulance arrived on scene 
and transported the patient to North Tees Hospital.  

5 

 
 
 
 06/07/22 - 999 call was made by the patient and triaged as a Category 2 emergency 
ambulance response. A double crewed emergency ambulance arrived on scene 
and transported the patient to North Tees Hospital.  

18/07/22 - 999 call received from Cleveland Police which was triaged as a Category 
3 emergency ambulance response. Two double crewed emergency ambulances 
attended scene, with one as backup at the request from the first crew. The patient 
was transported to North Tees Hospital.  

In considering bookings for transportation made via the Patient Transport Service 
(PTS), upon checking the records covering the same period, we have two bookings 
made as follows: 

13/10/2021 – Booking made via a GP for transportation from the patients home 
address to an outpatient’s appointment at Newcastle Freeman Hospital. The 
transportation was provided by a Patient Transport Service car.  

13/10/2021 – Booking made via a GP for transportation from Newcastle Freeman 
Hospital  back  to  the  patients  home  address  following  the  outpatient’s 
appointment. The transportation was provided by a Patient Transport Service car. 

During the inquest you heard verbal evidence from a NEAS Clinical Section Manager 
who advised that in respect to the call on 18 July 2022, a taxi was not considered and 
would not have been appropriate given the nature of the call. The review of the clinician’s 
call undertaken by another Clinical Section Manager, shows that some red flags existed 
and should have prompted a higher level of caution, therefore the use of a taxi would 
not be appropriate. This was on the basis that the caller was expressing suicidal intent 
and plans, therefore not safe or appropriate to send a taxi in these circumstances. We 
have  previously  disclosed  this  report  to  your  office  and  this  was  covered  during  live 
evidence  by  the  Clinical Section  Manager attending  the  inquest.  The  Management  of 
Long  Waits  procedure  which  was  disclosed  provides  details  in  respect  to  use  of 
alternative transport following an assessment by a clinician.  

Section  7.1  of  the  procedure  states:    “the  trust  has  deemed  that  where,  following 
assessment, a patient is clinically suitable to travel in a non-blue light transport, such as 
a taxi or PTS vehicle, i.e. requires no clinical intervention or supervision, able to sit in a 
car and transfer in and out of a car with minimal assistance and where all other options 
have  been  exhausted  (self-conveying  or  relative);  a  Trust  approved  alternative 
conveyance may be organised by the clinician. 

In respect to the concern that a taxi was not considered, given the red flags and nature 
of  the  call,  a  taxi  would  not  be  appropriate  for  this  type  of  call  and  therefore  is  not 
mentioned in the call notes as the case remained a Category 3 emergency ambulance 
response.  

6 

 
 
 
 
 
 
 In relation to the Management of Long Waits Policy, this policy was removed from use 
on  25  August  2022  and  was  replaced  with  the  Procedure  for  Emergency  Ambulance 
Response  Validation  and  was  implemented  on  25  August  2022.  The  new  procedure 
provides a process whereby welfare calls are only required to be made to patients who 
are alone. In these cases, the clinician is required to update the notes to make it clear 
when  viewing  the  case  list  whether  a  welfare  call  is  required  or  not  by  documenting 
‘welfare’ or ‘no welfare’. 

The  changes  were  introduced  following  a  Quality  Improvement  process  based  on 
evidence which showed only a small proportion of calls were receiving a welfare call. It 
was felt that the greater risk related to patients who are alone not receiving a call, versus 
a patient who has someone present receiving a call. If a similar scenario was dealt with 
now, the patient would receive a welfare call based on the updated procedure to prioritise 
those patients who are alone. 

The Emergency Ambulance Response Validation procedure also includes a section on 
alternative transport which is at section 1.5, page 3 of the procedure which is enclosed.  

Section 1.5.1 states: “If during a validation call, it is identified that alternative transport 
can be utilised, e.g. urgent crew, scheduled care crew, or taxi the instructions field will 
be  populated  with  ALT  in  addition  to  the  time  of  the  validation  and  this  will  notify  the 
dispatch team that alternative transport can be utilised. The clinician will document in the 
case notes the type of transport required and the patient’s mobility”. 

Section 1.5.2 states: “If a crew has been allocated to a case and alternative transport is 
appropriate, the save and notify function should be used to notify the dispatch team that 
an emergency vehicle is not necessary”. 

As  you  will  note  the  current  procedure  includes  the  requirement  to  add  notes  to  the 
system  to  identify  that  alternative  transport  can  be  utilised  and  what  type  is  required 
based upon their assessment.  

I hope that this addresses the matters of concern which you have highlighted.  If we can be of 
any  further  assistance  then  please  do  not  hesitate  to  contact 

Yours sincerely 

Chief Executive 

Enclosures: 

Forcible Entry Memorandum of Understanding (current) 
Standard Operating Procedures (SOPS) for Unscheduled Care Dispatch Staff 
Operation Alert – forcible entry 
Forcible Entry Guidance Note – Call Handling Staff 
Joint Partnership Management Group Terms of Reference 
Emergency Ambulance Response Validation Procedure 

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