07 December 2018

Before HM Senior Coroner Terence Carney  
Gateshead & South Tyneside Coroners Court
7 – 10 December 2018

The inquest into the death of James ‘Jimmy’ Quinn, 61, has concluded finding failures by Northumbria Police and North East Ambulance Service meant Jimmy died from otherwise potentially survivable injuries. The ambulance and police services failed to access Jimmy’s locked house in Washington, Tyne and Wear, for 55 minutes after he called for emergency help. This was due to a series of catastrophic misunderstandings of information and a lack of clear protocol.

The conclusion followed three days of evidence heard before HM Senior Coroner Terence Carney, who called the services in place for forcibly entering properties “fatally flawed”, and said, “The informality of the arrangement between police and ambulance service is astounding the modern age.”

On the evening of 1 July 2016, Jimmy sustained serious injuries to his right arm after falling into a glass cabinet at home. Jimmy quickly phoned 999 and asked for an ambulance. The first call was recorded at 19.05. He told the operator that he had fallen down and that “his arm was hanging off”. The operator could not discern the address and asked a Team Leader to listen to the tape. She also failed to record a vital piece of information about the seriousness of Jimmy’s injuries which should have triggered immediate dispatch of an ambulance, to arrive at Jimmy’s home in 8 minutes or less.

Jimmy phoned 999 for a second time at 19.22 a short while later and spoke to a different call handler who did grade the call correctly. Jimmy told the operator that he could not get to the door, that he kept passing out, and that his front door was locked so they would need to break in. The ambulance service made contact with the police, made clear what had happened, and received confirmation that officers would attend to provide assistance in gaining entry to Jimmy’s home.

When that message was passed on within Northumbria Police it was disastrously misinterpreted, such that a police officer made the decision to delay the attendance of officers under the erroneous belief that the ambulance service would make further contact with the police if they were required to attend. The inquest also heard that the police failed to grade their response appropriately.

The ambulance arrived and soon after Jimmy’s partner and sister were notified by a neighbour. The paramedics decided not to force entry to the property themselves, in part because they considered it unsafe to do so, and in part because of a mistaken belief that they were legally prohibited from entering. The inquest heard that ambulance staff at the time had no training about forcible entry.

Dr Peter Goode, Consultant in Accident and Emergency Medicine, gave expert evidence to the inquest and concluded that Jimmy’s injuries were survivable with prompt assessment and treatment. He said that up until 19.46 there was still a probable chance that with treatment he would have survived. By that point, the police had still not been dispatched, and the paramedics were waiting outside of the property under the belief that police would be arriving imminently.

Jimmy’s partner and sister arrived and tried to gain entry with a key but it snapped due to his key being in the lock on the other side. They asked the paramedics to break in. The police had still not been dispatched by this point. By this time it was 19.56, 20 minutes after the incident was sent to the police control room. When officers finally arrived and gained entry a little after 20.00 Jimmy’s injuries had become fatal and he later died in hospital.

The coroner found that Jimmy called for assistance and that assistance could and should have been delivered in a much more timely fashion than it was. He went on to note that if it had been, the outcome could have been different: his life could have been saved.

Responding to the conclusions, Jimmy’s family said: We would like to thank our Barrister Paul Clark and Solicitor Gemma Vine for their help and support. It is of huge relief that our concerns have now been recognised. Jimmy is missed deeply by all of his family and friends.

Gemma Vine, Solicitor for Jimmy’s family said: “This is a tragic case of an utterly preventable death which has occurred due to numerous mistakes and critical time delays by those emergency services that are supposed to be there to help us. Jimmy called 999 in his hour of need and was profoundly let down, resulting in his untimely death. We just hope that North East Ambulance Service and Northumbria Police take on board all of the lessons learned from Jimmy’s tragic death to prevent other unnecessary deaths occurring in the future.”

Deborah Coles, Director of INQUEST said: “Jimmy called for help but was left to die by the police and ambulance services, whose informal and confused practices were clearly not fit for purpose. This death could happen to anyone. This should give rise to urgent action by in regard to joint working between emergency services nationally.”



For more information please contact Lucy McKay on email or 020 7263 1111

The family is represented by INQUEST Lawyers Group members Gemma Vine of Minton Morrill Solicitors, Leeds and Paul Clark, Garden Court Chambers London.

As well as the family, interested persons represented at the inquest were Northumbria Police and North East Ambulance Service.

The medical cause of death confirmed by the pathologist was exsanguination caused by an incised injury to the right forearm with a severed ulnar artery.

The coroner’s full conclusion was: “Due to a failure to send an ambulance earlier and a failure by police to respond promptly to a request for attendance, there was a time critical delay in the delivery of essential medical care, and Mr. Quinn died from otherwise potentially survivable injuries inadvertently sustained in a fall.”

HM Senior Coroner Terence Carney also told the inquest “The services that were in place may have worked on other occasions. But they were fatally flawed. I am told that the police and ambulance service have not been able to find any documentation about arrangements between them (governing forcible entry to property). The informality of the arrangement between police and ambulance service is astounding the modern age. The fact that cooperation involved a decision not to train staff in forcible entry, and to discourage them from carrying out forcible entry, underlines an essential need to ensure that the system was robust, and that it was followed, to provide an obvious solution to an obvious need.”