Press Release – June 2025
Before Senior Coroner Clare Bailey
Teesside Coroners Court, Victoria Square, Middlesbrough TS1 2AS
Scheduled 9-11 June 2025
Peter Coates died on 14 March 2019. Peter was a much-loved father and grandfather.
Peter had worked at Redcar British Steel for all of his working life. He developed lung cancer later in life and although he beat the cancer and remained in complete remission, he never regained his full health and soon after was diagnosed with COPD. He became dependent on oxygen from the CPAP machine in his bedroom and relied on portable oxygen bottles for when he was able to move from his bed.
On 14 March 2019 a power cut in his local area caused the CPAP machine to fail. He called for an ambulance to inform them that the machine was not working due to the power cut, and he could not access his portable oxygen.
The first ambulance that was dispatched was in a local ambulance station only minutes away from his house. Due to the power cut the automatic gates would not open and staff present at the station that evening did not know how to manually override the gates.
A second ambulance was dispatched to his house but stopped at a petrol station on the way. There was also a delay in accessing the property as they could not find the key safe, despite the information being provided by Peter to the call handler when he called 999. Once entry was gained Peter had already died.
Peter’s death was originally recorded as a natural cause. However, his case was reviewed as part of Dame Marianne Griffiths Independent Review into North East Ambulance Service[1] and a number of critical findings were made. Following the publication of the report submissions were made to the Senior Coroner that the inquest should be reopened into Peter’s death and on 14 August the inquest was reopened.
Representing Peter’s family, Gemma Vine, solicitor from Ison Harrison, said: “The inquest will explore serious concerns around the actions of NEAS on 14 March 2019, including delays caused when the first ambulance crew were unable to manually override the gates to the station, and further delays when the second crew stopped at a petrol station and then struggled to locate the key safe. It will also examine whether the policies, procedures, and training in place at the time were appropriate, or whether they contributed to avoidable delays that could have impacted the response that day.”
ENDS
For further information or to note your interest, please contact Gemma Vine – gemma.vine@isonharrison.co.uk
Peter’s family are represented by Gemma Vine of Ison Harrison Limited and Counsel Paul Clark of Garden Court Chambers.
[1] The Report of the Independent Review into alleged failures of patient safety and governance at the North East Ambulance Service (NEAS) This review was undertaken following media coverage after a former employee raised concerns about multiple cases involving NEAS.
