Source · Prevention of Future Deaths

Yunus Hoque

Ref: 2026-0113 Date: 26 Feb 2026 Coroner: Benjamin Myers Area: Manchester South Responses identified: 1 / 1 View PDF

NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.

Date 26 Feb 2026

56-day deadline 23 Apr 2026

Responses identified 1 of 1

Child Death (from 2015) Emergency services related deaths (2019 onwards)

Coroner's concerns

AI summary

NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.

View full coroner's concerns

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.

Responses

1 respondent

NWAS Other

21 Apr 2026 PDF

Action Taken

• NWAS has implemented a number of steps to ensure more accurate estimated time of arrival information is provided to callers. • Estimated times of arrival are now provided based on information from each of the areas within the Trust: North Cumbria, South Cumbria and Lancashire, Greater Manchester, and Cheshire and Merseyside. (AI summary)

View full response

Dear Mr Myers

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

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.

Report sections

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.

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.

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Report details

Reference: 2026-0113
Date of report: 26 February 2026
Coroner: Benjamin Myers
Coroner area: Manchester South

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Apr 2026.

Sent to

North West Ambulance Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.