An coroner has criticised the emergency services after it took 357 minutes for an ambulance to arrive at the home of a suicidal man.

A coroner has said that a Northamptonshire man was ‘let down’ by the authorities after he told them he was going to take his own life.

Samuel Hand, 32, died on March 23, 2025, hours after he had called 999 to tell them he had taken a significant overdose.

Now, following an inquest into his death, senior coroner Anne Pember has issued a report to try to prevent future deaths of a similar nature.

Mr Hand phoned the Mental Health Hub, run by Northamptonshire Healthcare NHS Foundation Trust, and the East Midlands Ambulance Service in the early hours of March 22 last year to ask for help with suicidal ideation.

“He was let down by both services,” said Mrs Pember in her Regulation 28 report.

He had consumed an excess of alcohol along with another unnamed substance.

The inquest, held on August 26, heard that Mr Hand had a long history of mental health problems, emotional unstable personality disorder, drug overdose, bi-polar disorder and suicidal ideation.

An earlier call to emergency services was placed in ‘category 3’ and at 4.36am Mr Hand made a 999 call to EMAS saying he had taken a significant overdose.

Mrs Pember’s report said: “He advised EMAS that he had got it in his head what he wanted to do to end his life but would not disclose it and would just go and do it.

"Again this was given a category 3 disposition.” It was not until 7.17am that Mr Hand’s case was placed in category 2 and a double-crewed ambulance was dispatched. It arrived at Mr Hand’s address at 8.01am, 357 minutes after the first call, and he was sadly declared dead 39 minutes later. Mrs Pember’s report said: “During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. “Mr Hand made a 999 to EMAS at 4.36am. During this call he clearly stated he had taken a significant overdose.

"He clearly expressed suicidal ideation. Evidence was given at the inquest that the reason for the category 3 disposition was that the ‘conversation did not disclose any of the high risk drugs that enable a higher disposition. Under the NHS Pathways this is a category 3’.” “It is clear that no consideration was given to the number of tablets taken when deciding the relevant category for disposition. Concentration appears to be entirely on the type of drugs used.”

Mrs Pember issued her report on August 14 but it has only recently been made public. She asked the Department of Health and Social Care, NHS England and the East Midlands Ambulance Service to respond so her concerns. NHS England have not yet done so.

The Department of Health and Social Care said, in a response to this newspaper,: “Our deepest sympathies are with the loved ones of Samuel Hand. His story is a tragedy, and we are determined to learn the lessons from it.

“We recognise the importance of earlier intervention and support for those who suffer with mental health difficulties, which is why this government is investing a record £16.3 billion into mental health services in 2026 to 2027, a real terms increase of around £180 million.

“On top of this, we are delivering the cross-government Suicide Prevention Strategy for England, identifying priority areas for action to reduce suicides and exploring opportunities to go further.”

EMAS referred our reporter to their formal response to Mrs Pember’s report, which said: “The Trust is increasing frontline capacity to support more timely emergency care, including for patients reporting an overdose or other high-risk presentations.

“Through its Right Sizing Programme and Category 2 Improvement Fund plan, the Trust will introduce 20 additional double-crewed ambulances and 191 frontline staff by 31 December 2026, providing around 2,100 additional ambulance hours each week. An equivalent further increase is planned by April 2028. Delivery is monitored fortnightly and recruitment is progressing. These measures are intended to improve ambulance availability and support achievement of a mean Category 2 response time of 30 minutes or less.”