East of England Ambulance NHS Trust
NHS / Health Body
Action Taken
• An article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call. • This will also be discussed at the Learning Group where potential themes are discussed. (AI summary)
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Dear HM Coroner Robin Weyell
I am writing further to the inquest into the death of Edna May Wiggett, which concluded on 13 March 2026. I understand you did not call any live witnesses from EEAST to attend the inquest in respect of the handling of the 999 calls on 19 and 20 September 2025, however you did request an investigation report to address the management of the calls shortly before the inquest.
This investigation report identified that, although the first 999 call received for Mrs Wiggett was triaged correctly and appropriately managed, there was a missed opportunity in respect of the second 999 call to re-triage the call based on her changing presentation. The report further confirms that EEAST was under significant operational pressure that night, arising from high call demand and delays in ambulance handovers at acute hospitals across the region.
Following the inquest you issued a Regulation 28 (Preventing Future Death) report to EEAST outlining your concern that
1) the failure to re-triage Mrs Wiggett’s case and consider a re- classification following receipt of a second call providing relevant East of England Ambulance Service NHS Trust
EEAST Whiting Way Melbourn SG8 6NA
Chief Executive: Neill Moloney Chair: Mrunal Sisodia OBE
information (an increase in pain) led to delays in the dispatch of an ambulance.
A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.
Please do not hesitate to contact me should you require any further information.
I am writing further to the inquest into the death of Edna May Wiggett, which concluded on 13 March 2026. I understand you did not call any live witnesses from EEAST to attend the inquest in respect of the handling of the 999 calls on 19 and 20 September 2025, however you did request an investigation report to address the management of the calls shortly before the inquest.
This investigation report identified that, although the first 999 call received for Mrs Wiggett was triaged correctly and appropriately managed, there was a missed opportunity in respect of the second 999 call to re-triage the call based on her changing presentation. The report further confirms that EEAST was under significant operational pressure that night, arising from high call demand and delays in ambulance handovers at acute hospitals across the region.
Following the inquest you issued a Regulation 28 (Preventing Future Death) report to EEAST outlining your concern that
1) the failure to re-triage Mrs Wiggett’s case and consider a re- classification following receipt of a second call providing relevant East of England Ambulance Service NHS Trust
EEAST Whiting Way Melbourn SG8 6NA
Chief Executive: Neill Moloney Chair: Mrunal Sisodia OBE
information (an increase in pain) led to delays in the dispatch of an ambulance.
A re-triage at the point of the second call was unlikely to have resulted in a higher categorisation as pain is not included within the triage questions, set out by the Advanced Medical Priority Dispatch System (AMPDS – the system used to triage 999 calls). However an article was published in the Emergency Operations Centre (EOC) Patient Safety and Experience Newsletter to remind staff to re-triage these types of call and this will also be discussed at the Learning Group where potential themes are discussed. This information could have been included in the investigation report to assist the court and this has been communicated internally for consideration.
Please do not hesitate to contact me should you require any further information.