Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0154, written 23 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Mar 2026 |
|---|---|
| Reference | 2026-0154 |
| Deceased | Peter Coates |
| Coroner | Paul Appleton |
| Coroner area | Teesside and Hartlepool |
| Category | Other related deaths · Emergency services related deaths (2019 onwards) |
| Organisation named | North East Ambulance Service NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
This document was classified as: OFFICIAL Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 1 CORONER I am Mr Paul M Appleton, HM Area Coroner for the Coroner Area of Teesside & Hartlepool. 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 15 March 2019 an investigation was commenced into the death of Peter COATES, aged 62 (born 13.04.1956). The investigation concluded at the end of the inquest on 20.03.2026. The conclusion of the inquest was a narrative conclusion as follows: “Peter died due to complications of Very Severe Chronic Obstructive Pulmonary Disease, with his death contributed to by the consequences of Obesity. Peter would not have died when he did, in the absence of an unplanned electrical power supply failure to his home address which caused his mains operated, bilevel positive airway pressure (BiPAP) and oxygen concentrator equipment to stop working.” I found Peter’s medical cause of death to be: 1a) Complications of Very Severe Chronic Obstructive Pulmonary Disease. 2) Obesity. 4 CIRCUMSTANCES OF THE DEATH Peter Coates’ past medical history included Very Severe Chronic Obstructive Pulmonary Disease (“COPD”) and Obesity. Peter sadly died at his home address of 42 Boulby Road, Redcar on 14.03.2019. Due to the severity of his COPD, Peter was reliant on at home, mains operated, clinical equipment, namely a bilevel positive airway pressure (BiPAP) machine and an oxygen concentrator. At 03:57 on 14.03.2019, Peter’s home address lost electrical power due to an unplanned electrical power supply failure. At 04:01, Peter contacted 999 and spoke to a Health Advisor at the North East Ambulance Service NHS Foundation Trust. During this telephone call, information provided by Peter included that: he had COPD and used an oxygen machine but there had been a power cut, he was struggling to breathe, could not reach his portable oxygen cylinders, and was home alone. Peter also confirmed the approximate location of, and the code for, a key safe at his home address. The key safe code was included in the crew notes subsequently made available to the attending Paramedics; however, the approximate key safe location was not included in the crew notes. Regulation 28 – After Inquest Document Template Updated 30/07/2021 This document was classified as: OFFICIAL A category 2 emergency ambulance response was assigned to Peter. I heard that the national Ambulance Response Programme requires, for category 2 responses, an overall average response time within 18 minutes, and a response to 90% of category 2 calls within 40 minutes. An ambulance crew was allocated to Peter at 04:04. That ambulance crew had an expected journey time to Peter’s home address of 1 minute and 37 seconds. That ambulance crew was, however, unable to depart from the ambulance station, due to the power failure meaning the electrically powered station gates would not open, with relevant staff being unaware of how to manually open the station gates. At 04:15, the category 2 emergency ambulance response to Peter was reallocated to a different ambulance crew. That ambulance crew, whilst travelling to Peter’s home address, stopped at a petrol garage to refuel at 04:23, leaving the petrol garage at 04:27, and arriving at Peter’s home address at 04:38. Following their arrival, the attending ambulance crew were initially unable to find the key safe and/or gain access to Peter’s property. Having located the key safe, the ambulance crew gained entry to Peter’s property at or around 04:48 and shortly thereafter found Peter to sadly be deceased on his bed. It was noted by the attending ambulance crew that Peter had obtained a portable oxygen cylinder, which was not dependent on a mains electricity supply, and which was delivering oxygen via a nasal cannula. The electrical power supply to Peter’s property was restored at 05:14 on 14.03.2019. Peter died due to complications of Very Severe COPD, with his death contributed to by the consequences of Obesity. Peter would not have died when he did, in the absence of the unplanned electrical power supply failure. Peter’s death was possibly contributed to by delays in the arrival of the ambulance crew to him. I heard evidence at the inquest hearing that a category 1 emergency ambulance response could not have been generated for Peter, as he was breathing and conscious at the time of the 04:01 999 telephone call. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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: In respect of the National Ambulance Response Programme, I understand from the evidence that: - Category 1 is an immediate response to a life-threatening condition. It should only be used for a patient who requires resuscitation or emergency intervention from the ambulance service, for example, a patient who is in cardiac or respiratory arrest. Mortality rates are high where a difference of one minute in response time is likely to affect outcome and there is evidence to support the fastest response. The national standard is for 90% of Category 1 patients to have received a response within 15 minutes; and for the overall average response time to be within 7 minutes. - Category 2 is for serious conditions, for example stroke or chest pain, that may require rapid assessment and/or urgent transport. Mortality rates are lower; a difference of an extra 15 minutes’ response time is unlikely to affect outcome and there is evidence to support an early dispatch. The national standard is for 90% of patients to have received Regulation 28 – After Inquest Document Template Updated 30/07/2021 This document was classified as: OFFICIAL a response within 40 minutes; and for the overall average response time to be within 18 minutes. My concern is that there are circumstances in which a patient is not, at the time a 999 call is made to request an Ambulance, in a condition such as cardiac or respiratory arrest; but where an immediate response is still required on the basis that delay in ambulance attendance could pose a risk to their life. That is, I am concerned that there is a category of patients who do not meet the criteria for a category 1 response, but who do nonetheless require an immediate response, and that there is, therefore, a “gap” between categories 1 and 2. This includes for patients who are alone at the time of calling 999 and who are therefore unable to update the Ambulance Service should they progress to cardiac or respiratory arrest. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 18 May 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: 1. Peter’s Family. 2. North East Ambulance Service NHS Foundation Trust. I have also sent it to: 1. Association of Ambulance Chief Executives (AACE). 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 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 by the Chief Coroner. 9 Dated: 23 March 2026 Mr Paul M Appleton HM Area Coroner for the Coroner Area of Teesside & Hartlepool. Regulation 28 – After Inquest Document Template Updated 30/07/2021
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 Paul M Appleton
HM Area Coroner for Teesside & Hartlepool
Middlesbrough Town Hall
Albert Road
Middlesbrough
TS1 2QJ
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
6th May 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Peter Coates who died on
14th March 2019
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23rd
March 2026 concerning the death of Peter Coates on 14th March 2019. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Peter’s family and loved ones. NHS England is keen to assure
the family and yourself that the concerns raised about Peter’s care have been listened
to and reflected upon.
Your Report raises concern that there may be circumstances when a patient requires
an immediate ambulance response but they are not in cardiac or respiratory distress
and therefore these patients do not meet the criteria for a Category 1 response. You
are concerned that there is a “gap” for patients that fall between Category 1 and 2
responses.
In 2017, following the largest clinical ambulance trials in the world, NHS England
implemented new ambulance standards across the country. This was to ensure that
the sickest patients get the fastest response and that all patients get the right response
first time.
NHS Ambulance Services are required to process 999 calls through an approved
triage system. There are currently two long established systems approved in England
for primary 999 triage; NHS Pathways and Medical Priority Dispatch System (MPDS).
The systems are used to prioritise 999 calls received into Ambulance Services’
Emergency Operations Centres (EOCs).
The primary purpose of triage is to quickly identify priority symptoms (e.g.
unconsciousness, difficulty breathing, chest pain) and to assign an appropriate
response priority. The outcome (disposition) reached based on the information
provided by the caller is mapped to one of the five national categories (Categories 1 –
5) set out within the NHS Constitution and Ambulance Service 999 contracts. The
development of triage question sets and instructions lies within the remit of the triage
system provider.
The current ambulance categorisations ensure that all emergency responses are
prioritised appropriately; Category 1 covers the most urgent, life-threatening cases,
while Category 2 addresses emergency but less critical incidents. These two
categories are sufficient for effective triage and timely intervention for life threatening
and emergency conditions.
In cases where there is risk of a patient’s condition deteriorating whilst waiting for an
ambulance to arrive, the call handler could stay on the line with the patient; this is an
operational decision to be made by each ambulance service. Moreover, the provision
of instructions or actions to be taken in the case of worsening patients is a standard
component of call exit scripts, whereby patients are advised that if their condition
worsens, they should call 999 back. This provides an opportunity for a call to be re-
triaged and potentially upgraded to a higher category response if this is clinically
indicated.
In cases where a patient is dependent on a piece of medical equipment e.g.
continuous BiPAP, the accountable clinician who is responsible for overall care of the
patient (e.g. their GP or hospital consultant) may wish to flag the patient to the local
ambulance service to enable the ambulance service to make a note on the patient’s
details within the services’ records system. This can be recorded in the urgent care
plan or summary care record dependent on the local service. Then, if the patient /
carer contacts 999 and is presenting with a problem relating to this equipment /
medical device they can be managed rapidly to receive the appropriate care.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of Peter,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Director of Patient Safety
NHS England
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