A coroner has warned of a "significant risk of future deaths" after ambulance delays contributed to the death of a County Durham man with a life-threatening airway obstruction.
A Prevention of Future Deaths (PFD) report has been issued following the death of 32-year-old Andrew Watson at his supported living complex in Langley Moor in October 2019.
At the conclusion of a five-day inquest in July, County Durham and Darlington Area Coroner Crispin Oliver, ruled Andrew died because lifesaving emergency treatment was not delivered in time due to delays by the ambulance service.
Andrew Watson (Image: FAMILY)
Now, writing in a PFD report, he raises concerns over how emergency calls are categorised.
Mr Oliver wrote: "In my opinion, unless action is taken to address the above concerns then there is a significant risk of future deaths".
The coroner raised concerns that choking caused by a foreign object generates a 'category one' ambulance response.
But Andrew was struggling to breathe due to quinsy, an inflammation of the tonsils. Mr Oliver noted choking caused by a natural condition, which can be equally life-threatening, generates a 'category two' response.
Andrew Watson (Image: FAMILY)
The report states the coroner was concerned a "clearly life-threatening condition, albeit preventable with critical care intervention" was treated as category two, rather than category one.
NHS England defended the triage system, saying Andrew’s category two response was based on his condition at the time.
Andrew Watson (Image: FAMILY)
NHS England said it could not comment on Andrew’s exact assessment because it did not have the 999 call recording, but said NHS Pathways does not downgrade a response because a patient cannot make the call themselves.
NHS England said: "NHS Pathways assesses the symptoms and level of compromise identified during the assessment, regardless of whether the patient or a third party is speaking to the Health Advisor."
It said the category two response for respiratory distress reflects the national clinical view that an 18 minute response is appropriate.
NHS England also defended the distinction between choking on a foreign object and other causes of airway obstruction.
It said a patient choking on a foreign object receives a category one response, while a conscious patient with breathing difficulties receives category two if the problem is not linked to anaphylaxis or a foreign-body blockage.
Andrew Watson with his family (Image: FAMILY)
Adding: "To allocate a category one disposition solely because deterioration might occur would not be consistent with the principles of clinical triage or national ambulance response standards."
The response added that if a patient's condition worsens or further information becomes available, the case can be reassessed and the response priority escalated.
The call was prioritised at 5.42pm, but an ambulance and paramedics did not reach him at Cecil Court in Langley Moor until 6.45pm.
At the conclusion of the inquest, the coroner said: "Had ambulances been more readily available, Andrew probably would have survived. In effect, service delays contributed to his death."
Andrew Watson with his family (Image: FAMILY)
NHS England said ambulance response times have improved since Andrew's death, adding: "NHS England is keen to assure the family and yourself that the concerns raised about Andrew’s care have been listened to and reflected upon."
It also offered its "deep condolences" to Andrew’s family and loved ones.
It said North East Ambulance Service’s average category 2 response time fell from 32 minutes 17 seconds in October 2019 to 21 minutes 14 seconds by October 2025.
The case was reopened after internal North East Ambulance Service investigations were not disclosed to Andrew's family and came to light in 2023 after a whistleblower contacted journalists.
Expert evidence heard at the inquest concluded Andrew may have survived if he had reached hospital 10 to 20 minutes earlier for emergency airway surgery.
North East Ambulance Service acknowledged that it did not respond as quickly as it should have.