Coroner's warning after ambulance delays possibly contributed to death of Northamptonshire man who took his own life

Liam Paul McCarlie died by suicide on April 1, 2023 after there was a significant delay in an ambulance attending to him following an emergency call.

Coroner Jonathan Dixey said the ambulance service delay and a lack of proactive support for Mr McCarlie’s mental health in the months prior could have contributed to his death.

A Prevention of Future Deaths Report was published after an inquest into Mr McCarlie’s death was concluded on June 5, 2024. The report said that on the evening of his death Mr McCarlie’s father and step-mother contacted the ambulance service after he sent a text expressing his intention to take his own life.

The call, which was made just before 6pm, was assessed as requiring a 120 minute response time. The report added that two ambulance crews were assigned to attend the scene at roughly 8.30pm and 10pm, but were stood down to attend higher priority calls.

A third ambulance arrived just after 11pm, five hours and 20 minutes after the initial call was made. Mr McCarlie’s death was confirmed by paramedics at 12.33am on April 2, 2023.

Coroner Mr Dixey wrote: “Had the ambulance service arrived within the required response time, it would have done so at a time when Mr McCarlie was still alive.”

The last recorded call from Mr McCarlie was at 7.26pm and the last recorded text message was sent at 8.18pm.

The coroner asserted that this delay, caused by an increased demand on the ambulance service, contributed to Mr McCarlie’s death.

Mr Dixey also reported that the man’s mental health “deteriorated significantly” in the months before his death. He was referred to a Structured Clinical Management programme in February of that year but was never formally assessed for it.

The coroner concluded that this “possibly” contributed to his death.

Mr Dixey warned that action should be taken to prevent future deaths and that the services “have the power” to do so.

He said that access to mental health records by the East Midlands Ambulance Service (EMAS), for example whether the patient has a history of suicidal ideation or attempts, “may in turn be material to the triage and dispatch of ambulance resources”.

Keeley Sheldon, director of quality improvement and patient safety at East Midlands Ambulance Service said: “Our sincere condolences go to Liam’s family, friends and all who knew him, at this difficult time.

“We take matters of patient safety regarding delays and responsiveness of our service very seriously.”

A spokesperson for Northamptonshire ICB added: “Our thoughts continue to be with Liam’s family and friends, and we would like to extend our sincerest sympathies to them.”

Both organisations said they were reviewing the report and will work together with partners to identify and implement any actions possible.

The EMAS and the Northamptonshire Integrated Care Board have until August 20 to respond to the report. This must contain a timetable and details of the action proposed, or an explanation as to why no action is proposed.

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