A 67-minute delay in getting an ambulance to a County Durham man suffering a medical emergency contributed to his death, a coroner has ruled.
Andrew Watson died on October 10, 2019, at his supported living complex Cecil Court in Langley Moor. He suffered respiratory failure caused by airway obstruction from quinsy, a rare complication of tonsillitis.
The 32-year-old's death was originally ruled to have been from natural causes at an inquest in 2020. But it later became the centre of allegations of a cover-up after internal investigations were not disclosed to his family and were only brought to light by a whistle blower.
His family only became aware those investigations had taken place in 2023 after being contacted by journalists, leading to the original inquest being quashed and a fresh hearing being scheduled.
At the conclusion of a five-day inquest today, Senior Assistant Coroner Crispin Oliver, ruled Andrew died because lifesaving emergency treatment was not delivered in time due to delays by the ambulance service.
He said Andrew was pronounced dead from "a critical medical condition requiring emergency treatment for survival. This was not delivered in time because delays in the response of the ambulance service."
Sitting at Crook Coroner's Court, he ruled Andrew's death was a "natural death to which the delayed arrival of an ambulance contributed."
The coroner accepted that "Andrew had been correctly triaged under the pathway algorithm" but added: "Had ambulances been more readily available, Andrew probably would have survived. In effect, service delays contributed to his death.
"The case was prioritised at 5.42pm and an ambulance and paramedics only arrived at Cecil Court at 6.45pm - over an hour after prioritisation, not 18 minutes. The reality was, according to Dr Sadek's (the expert witness) evidence, that at that point Andrew's medical condition had ceased to be survivable - in effect survivability had by then slid from improbable to impossible."
The inquest previously heard Andrew attended his GP on the morning of his death, where he was diagnosed with tonsillitis before his condition rapidly deteriorated hours later.
Nurse practitioner Jacqueline Griffiths told the inquest she specifically looked for signs of quinsy and found none, while accepting he could have been in the very early stages of the condition.
The inquest also examined the North East Ambulance Service's (NEAS) handling of three 999 calls after Andrew repeatedly told operators he was struggling to breathe. Despite being told an ambulance would arrive within 18 minutes, he waited 67 minutes before paramedics reached him.
Expert evidence concluded Andrew may have survived had he reached hospital 10 to 20 minutes earlier for emergency airway surgery, with consultant Dr Samy Sadek telling the court: "The response time made this impossible."
The inquest also focused on NEAS's actions after Andrew's death. Internal reviews found concerns over the prioritisation of his emergency calls and identified delays in the handling of his final 999 call.
Giving evidence, paramedic Catherine Wilson, who attended Andrew, said his death was preventable and described feeling "nobody was listening to us" when she argued internally that the incident should have been classified as the highest possible level of harm.
NEAS manager Donna Hay also gave evidence that she felt "under pressure" during the review process and believed those leading discussions already had "a conclusion in mind they wanted to reach" when deciding how the incident should be graded.
A regulation 28 prevention of future deaths report will be issued to NHS England.
Karen O’Brien, Deputy Chief Executive at North East Ambulance Service, said: “We are truly sorry for Andrew’s death and the distress caused to his family. We did not respond as quickly as we should have when he called us, and we have always acknowledged that this delay likely contributed to his death.
“We have taken significant steps since 2019 to reduce the delays to ambulance responses, which has included substantial investment in more paramedics and more ambulances. Today, our service is performing more strongly and reaching people faster.
“The coroner highlighted flaws in our investigation and governance processes at that time which was extensively reported upon in 2023 and have been addressed with oversight from NHS England.
“This has been a profoundly tragic case which has had an impact on everyone involved. We hope the inquest has provided answers for the family, although we know it does not ease the pain of their loss.”
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