Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0113, written 26 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Feb 2026 |
|---|---|
| Reference | 2026-0113 |
| Deceased | Yunus Hoque |
| Coroner | Benjamin Myers |
| Coroner area | Manchester South |
| Category | Child Death (from 2015) · 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: 1. North West Ambulance Service 1 CORONER I am Benjamin Myers KC, Assistant Coroner for the coroner area of Greater Manchester South 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 the 22nd January 2024, an inquest was opened concerning the death of Yunus Hoque, aged 13 years at the time of death. The inquest was heard with a jury on the 9th February 2026 to the 12th of February 2026. The jury found the medical cause of death to be: 1a) Multi-organ failure 1b) Group A Streptococcus bronchopneumonia and Sepsis The jury returned a conclusion of natural causes contributed to by neglect. 4 CIRCUMSTANCES OF THE DEATH On the 14th January 2024, Yunus Hoque became ill with a viral infection. Over the course of the following week he became increasingly unwell. A Group A streptococcal infection overlayed the viral infection. By the 18th January 2024, Yunus was struggling to lift his head from his pillow, he had a high temperature and he could not walk downstairs unaided. He was sleepy and ceased to eat. He continued to deteriorate. His mother called 111 at 22:42 hours on the 21st January 2024. The outcome of the assessment by North West Ambulance Service [‘NWAS’] in that call was that this was a Category 2 response. Category 2 had an average response time of 18 minutes. His mother was informed that there would be an ambulance in about an hour. By 00:52 no ambulance had attended, by which time Yunus was having a seizure. His mother called 999 and on assessment during that call, this was now a Category 1 response. The average response time for Category 1 was 7 minutes. An ambulance was allocated at 00:56 hours and arrived at Yunus’s home at 01:01 hours. Yunus arrived at Tameside General Hospital at 01:20 hours, by which time he was in respiratory arrest. He went into cardiac arrest at the hospital. There was no response to repeated attempts at resuscitation. Death was certified at 02:53 hours. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could 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 target response time for a Category 2 response was 18 minutes. The caller was told that an ambulance would be with Yunus in about an hour. 2. A period of approximately 2 hours elapsed during which no ambulance arrived, and before the caller, Yunus’s mother, called 999. During this period, no communication was received by the caller from NWAS, or on their behalf, to inform her that there would be this unforeseen delay. 3. During this 2 hour period, Yunus’s condition deteriorated further, moving from Category 2 to Category 1. 4. No further calls had been made by Yunus’s mother during this period because it was her understanding that an ambulance would be with Yunus within the period of time indicated in the first call. Therefore she waited. 5. The evidence at the inquest established that the categorization in each call was at the appropriate level. 6. However, it is apparent that in circumstances where there is a significant delay over and above that indicated to the caller, there is no follow-up call or communication to indicate further delay, to confirm the status of the patient, or to suggest that alternative transport is required, if possible. Notwithstanding this, in a changing situation, a patient may deteriorate, moving from Category 2 to Category 1 and therefore requiring a more urgent response: as was apparent from the evidence at this inquest. But a patient, family member and / or carer who relies upon information already provided by the call handler, may continue to wait for an ambulance that they have been told will arrive in a given period of time, when in reality there is no likelihood of that ambulance arriving. At the same time, NWAS will be proceeding on the basis that they are dealing with a Category 2 when the case has now become a Category 1. 7. The evidence established that Yunus was so ill by the time of the first call to 111 at 22:42 on 21st January 2024, that the delay in the arrival of an ambulance did not contribute to his death. 8. Nevertheless, the absence of any system for a follow-up call by or on behalf of NWAS in circumstances where an unforeseen delay in ambulance attendance is going to be far in excess of that indicated to the caller, creates a risk that further deaths could occur, given that during this period a patient may deteriorate and their categorization can move to Category 1 from a lower category. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [and/or your organization] 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 23rd April 2026. 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mother of Yunus Hoque, on behalf of the family, Tameside Metropolitan Borough Council, Tameside General Hospital who may find it useful or of interest I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. 9 Date: 26th February 2026 Benjamin Myers KC HM Assistant Coroner Greater Manchester South
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.
Mr Benjamin Myers KC His Majesty’s Assistant Coroner Greater Manchester South Coroners Court By Email Only 21 April 2026 Dear Mr Myers LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD nwas.nhs.uk Regulation 28 Report – Inquest Touching the Death of Yunus Hoque I write further to your Prevention of Future Deaths Report dated 26th February 2026, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Yunus Hoque. I am aware that you will share my response with Yunus’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter I will address those concerns as far as I am able. The absence of any system for a follow-up call by or on behalf of NWAS in circumstances where an unforeseen delay in ambulance attendance is going to be far in excess of that indicated to the caller, creates a risk that further deaths could occur, given that during this period a patient may deteriorate and their categorisation can move to Category 1 from a lower category. I can confirm that since Yunus’ death in January 2024, NWAS has implemented a number of steps to ensure more accurate estimated time of arrival information is provided to callers. Previously, estimated times of arrival were provided based on information taken from across the whole geographical area of the Trust. NWAS has since moved to providing estimated times from each of the areas within the Trust: North Cumbria, South Cumbria and Lancashire, Greater Manchester, and Cheshire and Merseyside. This provides the caller with a more accurate estimated time of arrival, as the different regions of the Trust experience different demand challenges throughout the day. In addition, following consistent monitoring to ensure the most accurate reading is taken to provide this information, it has been concluded that the ‘mean’ time provides the most accurate information which is now used across NWAS. When patients are waiting for an ambulance, I can confirm that the calls are regularly reviewed by senior clinicians Head uarters: Lad brid e Hall, 399 Chorley New Road, Bolton BL1 5DD Delivering the right care, at the right time, in the right place; every time. within our Contact Centres for potential deterioration. All waiting calls are also prioritised by these senior clinicians to ensure our ambulances are sent to our most critical patients as a priority. Unfortunately, this does not mean that we are able to provide an exact time of arrival for an ambulance, due to constraints on demand and the requirement to dispatch ambulances to the most critical patients in order of need. The reality is, with the finite resources available to the Trust, if NWAS were to carry out call-backs to patients to update them on unexpected changes to their estimated time of arrival, it would reduce our capacity to answer 999 calls for other patients and to provide essential information to callers. However, prior to the closure of each call, we provide interim care advice which gives the caller advice on how to care for the patient until the ambulance arrives. Full worsening advice is also provided, advising the caller to contact 999 straight away if there are any changes in the condition of the patient, if they are worried about the patient, or if they have any other concerns. This creates the opportunity for the patient’s condition to be re-triaged and the appropriate categorisation to be elicited for their symptoms and condition. In our experience, the most effective way to minimise waiting times and reduce anxiety for callers is to provide the most accurate estimated time of arrival possible at the time of the call, provide clear worsening advice, maintain clinical oversight of all waiting calls and reprioritise them based on clinical need, and maximise ambulance availability by using the full range of alternative care pathways across the North West. Nevertheless, I can confirm that NWAS are currently exploring the use of SMS text messaging to patients who are waiting for an ambulance or a further clinical assessment from an NWAS clinician or external provider. This work is in the initial stages but will provide improved information to our callers whilst they await a response. In addition to the above I would like to highlight that NWAS has made significant improvement in its Category 1 and 2 response times since Yunus’ death. This has been achieved by improving the number of responding ambulances available for dispatch by employing more Paramedics and Emergency Medical Technicians. We have also increased the number of clinicians telephoning patients to complete a full clinical triage and referring into alternative pathways of care. This enables our responding ambulances to attend to our most critically unwell patients who require a Category 1 or 2 response. I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, Emma Shiner. Yours sincerely Chief Executive
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