Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0433, written 20 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Aug 2025 |
|---|---|
| Reference | 2025-0433 |
| Deceased | Ricky O’Connell |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Department of Health and Social Care 1 CORONER I am Alison Mutch senior coroner, for the coroner area of South Manchester 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 INVESTIGATION and INQUEST On 3rd February 2025 I commenced an investigation into the death of Ricky O'CONNELL .The investigation concluded on the 2nd July 2025 and the conclusion was one of narrative: Died from acute myocardial ischaemia in the context of a significant delay in an ambulance attending following a 999 call. The medical cause of death was 1a) Acute Myocardial Ischaemia 1b) Coronary Atherosclerosis 4 CIRCUMSTANCES OF THE DEATH Ricky O'Connell's partner called for an ambulance at 05:44 when his overnight symptoms deteriorated and he was concerned he was having a heart attack. He was categorised as a category 2 call. On the Department of Health Standards that should result in an ambulance on average arriving within 18 minutes and in 9 out of 10 cases within 40 minutes. The ambulance had not arrived by 06:38 due to very significant delays across the North West, primarily due to prolonged hospital handovers and overall demand on the service. His partner called again. At 06:43 during that call he collapsed and the call was upgraded to Category 1. An Ambulance was dispatched (the earlier call was still in the queue for dispatch). CPR was given by his family and then the ambulance and he was transported to Tameside General Hospital where attempts to resuscitate him continued. He died at Tameside General Hospital on 27th January 2025. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise 1 to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed. The evidence given was that NWAS had done a huge amount of work to try to improve ambulance response times. This included improved staffing and call handling. However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr O’Connell. 2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services. The reasons for the demand were multi factorial and included challenges in accessing primary care. 3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further. On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances. This led to significant challenges for NWAS. 4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North West. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th October 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION 2 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the father of Mr O’Connell and North West Ambulance Service , who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 20/08/2025 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health and Secondary Care
39 Victoria Street
London
SW1H 0EU
HM Senior Coroner Alison Mutch
1 Mount Tabor Street
Stockport
SK1 3AG
15th October 2025
Dear Ms Mutch,
Thank you for the Regulation 28 report dated 20 August addressed to the Secretary of
State for Health and Social Care regarding the death of Ricky O’Connell. I am replying
as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to express my sincere condolences to Mr O’Connell’s family and
loved ones. The circumstances described in your report are deeply concerning and I
am grateful to you for bringing these matters to our attention.
Your report raises important concerns regarding ambulance response times and
handover delays. In preparing this response, my officials have consulted NHS England
(NHSE) and North West Ambulance Service (NWAS) to ensure your concerns are
addressed thoroughly.
The Government is committed to ensuring patients receive the highest standard of
care from the NHS. We acknowledge that the urgent and emergency care (UEC)
performance has not consistently met expectations in recent years, and we are taking
serious steps to address this. Building an NHS fit for the future is one of our five key
missions.
In June 2025, we published our 10-Year Health Plan which sets out how reforms
across the NHS, including UEC care services. The Plan outlines three major reform
shifts:
• From hospital to community, bringing care closer to where people live
• From analogue to digital, modernising services through technology
• From sickness to prevention, helping people stay healthier for longer
We also published our Urgent and Emergency Care Plan for 2025/26 in June which
focuses on improvements to deliver better UEC performance both daily and during
winter pressures. Key actions include:
• Nearly £450 million of capital investment for Same Day Emergency Care,
Mental Health Crisis Assessment Centres and new ambulances
• Reducing ambulance handovers to a maximum of 45 minutes, and Category 2
•
response times to 30 minutes on average
Improving patient flow through hospitals to 78% of patients seen in A&E
departments within 4 hours and reducing 12-hour waits
NHSE continues to work closely with ambulance trusts including NWAS to improve
Category 2 response times. You note there have been improvement in response times,
which is reflected in the latest performance figures:
•
•
In August 2025, the national average Category 2 response time was 27
minutes 3 seconds compared to 27 minutes 25 seconds in August last year.
In NWAS, the average response time was 23 minutes 4 seconds, well ahead
of the Government’s 30-minute recovery target.
Efforts to reduce ambulance handover delays are also progressing. NWAS reports
significant local collaboration between Integrated Care Boards (ICBs), Acute Trusts,
and NHSE regional teams. These efforts aim to ensure safe and timely patient
handovers, freeing up crews to respond to emergencies in the community.
• NWAS’s average handover time has improved from 26 minutes 24 seconds in
August 2024 to 22 minutes 35 seconds in August 2025.
• Their 90th centile handover time has also improved from 45 minutes 54
seconds to 39 minutes 4 seconds over the same period.
We will continue to monitor performance closely and work with NWAS and NHSE to
ensure sustained improvement. I hope this response provides reassurance that the
Government is taking meaningful action to improve urgent and emergency care
services. Thank you once again for raising these concerns.
Yours sincerely,
Minister of State for Health and Secondary Care
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