Source · Prevention of Future Deaths
Christopher Smith
Ref: 2015-0455
Date: 28 Oct 2015
Coroner: Simon Jones
Area: Manchester (West)
Responses identified: 0 / 1
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A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.
Date
28 Oct 2015
56-day deadline
23 Dec 2015 est.
Responses identified
0 of 1
Coroner's concerns
A 12-minute ambulance call delay resulted from communication breakdown between police control rooms regarding responsibility. A clear procedure is required to prevent future delays, especially when timely medical intervention is crucial.
View full coroner's concerns
In the circumstances it is my statutory duty to report to 1) It was clear from the evidence that there was a 12 minute in the police contacting the ambulance the police were notified of the incident but did not contact North West Ambulance Service immediately: his you: delay
2) In the circumstances of this Inquest I was satisfied that this had not had any relevance with regards to Christopher Smith's death, given that the pathologist had concluded that his death was instantaneous: Any delay in the ambulance arriving was therefore not going to save his life.
3) However, it is perfectly possible to foresee circumstances where a delay in calling for an ambulance may have an effect on the outcome, where someone has jumped or fallen from a lesser distance.
4) I was told that the 12 minute delay was due to a breakdown in communication between Greater Manchester Police control room and Motorway Control Greater Manchester Police thought that the Motorway Control were contacting the ambulance and vice versa.
5) It seems to me that procedure should be in place whereby it is immediately established who is going to be responsible for calling the ambulance to avoid any delays, and the ambulance is called for at once:
2) In the circumstances of this Inquest I was satisfied that this had not had any relevance with regards to Christopher Smith's death, given that the pathologist had concluded that his death was instantaneous: Any delay in the ambulance arriving was therefore not going to save his life.
3) However, it is perfectly possible to foresee circumstances where a delay in calling for an ambulance may have an effect on the outcome, where someone has jumped or fallen from a lesser distance.
4) I was told that the 12 minute delay was due to a breakdown in communication between Greater Manchester Police control room and Motorway Control Greater Manchester Police thought that the Motorway Control were contacting the ambulance and vice versa.
5) It seems to me that procedure should be in place whereby it is immediately established who is going to be responsible for calling the ambulance to avoid any delays, and the ambulance is called for at once:
Report sections
Investigation and inquest
On 22nd July 2015 I commenced an investigation into the death f Christopher John Smith; born on 27th December 1979. The investigation concluded at the end of the inquest on 21st October 2015. The medical cause of death was la) Multiple Injuries: The conclusion of the inquest was that Christopher John Smith committed suicide_
Circumstances of the death
On the 15th July 2015 the deceased, Christopher John Smith was seen driving motor vehicle across Barton Bridge in a northbound direction: He stopped the car on the left hand side of the inner lane, exited the vehicle and climbed over the railings Witnesses confirmed that he did not pause or hesitate; before jumping from the bridge to the rough ground below. He was confirmed dead at the scene and the pathologist who gave evidence at the Inquest confirmed that in his view, on a balance of probabilities, Christopher John Smith's death would have been instantaneous.
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Report details
- Reference
- 2015-0455
- Date of report
- 28 October 2015
- Coroner
- Simon Jones
- Coroner area
- Manchester (West)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Dec 2015 (estimated).
Sent to
- Greater Manchester Police