The daughter of a former steelworker who died after waiting almost 40 minutes for an ambulance while unable to breathe has said new evidence means there should now be an inquest into his death.

Peter Coates, 62, who had lung disease, used a machine for oxygen and dialled 999 when the electricity went off in a power cut and he began struggling for breath.

He called an ambulance and explained the urgency, but the nearest crew was unable to attend because the power cut also locked the gates at the station – four minutes away.

A second crew was scrambled but stopped to refuel, even though the ambulance’s tank was half full and could have easily reached Mr Coates’ Domanstown home near Redcar.

The Northern Echo: Mr Coates pictured with his grandson Oliver Mr Coates pictured with his grandson Oliver (Image: Contributor)Details of the catastrophic sequence of contributing factors that delayed paramedics reaching him before he died in the early hours of March 14, 2019, formed part of a damning review of North East Ambulance Service (NEAS).

Mr Coates’ daughter, Kellie, said his death was recorded as ‘natural causes’ by the coroner and no details of ambulance delays were reported so no inquest was held.

It forms part of the ‘cover up’ scandal exposed by a whistleblower, former policeman and coroners’ officer Paul Calvert, from Peterlee.

The Northern Echo: Paul Calvert Paul Calvert (Image: Northern Echo)

Ms Coates said: “The review has identified more details than we knew before.

“There are so many unanswered questions. It does not feel as though we have the full truth.

“There were gaps in the report and lengths of time that are not explained, why certain decisions were and that is what is missing for me.”  

The Northern Echo: Kellie Coates Kellie Coates (Image: Contributor)

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Ms Coates has also backed calls for public inquiry made by Mr Calvert and Tracey Beadle who was misled over the circumstances surrounding her 17-year-old daughter Quinn’s suicide in Shildon in 2018.

The review of NEAS was conducted by former hospital boss Dame Marianne Griffiths after concerns about up to 90 cases were identified by Mr Calvert.

Ms Coates said: “I think it needs a public inquiry.

“Dame Marianne has been supportive but I still feel like NEAS are holding things back.

“This new report has raised more questions.

“We are looking for the coroner to open an inquest. We have asked before and they seem quite reluctant but now this report has come out we believe there is new evidence to suggest they should be doing an inquest.”

The Northern Echo: Peter Coates Peter Coates (Image: Contributor)

Mr Coates, who had Chronic Obstructive Pulmonary Disease (COPD) and required 24-hour home oxygen therapy but was alone and could not get out of bed to access the alternative cylinder.

Despite the urgency the call was deemed to be ‘category 2’.

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In her report Dame Marianne said: “The family have a number of concerns relating to their father’s case.

“They do not feel that NEAS have acknowledged process failings and their contributing factor to their father’s death.

“The family’s contention is that if the ambulance had got there sooner their father might still be alive and that it was NEAS’s failures in processes that contributed to the likelihood of death.

“They also contend that he was very clear about the urgency of the oxygen when the 999 call was made. We have listened to the call and can attest to this fact.

“They therefore believe that this should have been treated from the onset as a serious incident.”

The Northern Echo: Dame Marianne Griffiths Dame Marianne Griffiths (Image: Contributor)

The report said the trust did not let the coroner know about the delays and reasons for delays. 

It said the coroner requested a statement from the responding paramedic in October 2019 but two statements were provided, one about the incident and refuelling and a second focussed only on the oxygen issues with no mention of issues about delays.

The report said: “The family do not believe this to be transparent and do not understand why the original statement was not shared with the coroner.”

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In May 2020, following an independent review of the coronial processes within the Trust, additional documents were provided to the coroner in this case.

These included all the paramedics reports and the incident reports.

The report said: “The matters came to their notice due to the whistle-blowing processes where their case was used as an example of a cover up.

“The fact that the ambulance paramedic was asked to provide a separate statement is a little unusual and, unfortunately, we have not been able to secure additional evidence as to why this was done.

“The decision not to share the original statement in 2019 has however affected the confidence of the family in respect of NEAS’s candour and transparency.”

The Northern Echo: Helen Ray Helen Ray (Image: Contributor)

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In response to the report NEAS chief executive Helen Ray issued an unreserved apology on behalf of the trust.

She said: “I would like to say how sorry I am for any distress caused to the families for mistakes made in the past.

“There were flaws in our processes and these have now either been addressed or are being resolved at pace.”