Brian Garrick
PFD Report
All Responded
Ref: 2025-0271
All 1 response received
· Deadline: 29 Jul 2025
Response Status
Responses
1 of 1
56-Day Deadline
29 Jul 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.
Responses
The DHSC stated that NHS England is working with systems to reduce ambulance handover delays, aiming for hospital handovers within 15 minutes and none longer than 45 minutes, supported by increased NHS funding and a new 10-Year Health Plan to reform urgent and emergency care services.
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Dear Mr Covell,
Thank you for the Regulation 28 report of 3 June 2025 sent to the Secretary of State for Health and Social Care regarding the death of Brian Garrick. I am replying as the Minister with responsibility for urgent and emergency care.
First, I would like to say how saddened I was to read of the circumstances of Mr Garrick’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns over ambulance waiting times and ambulance handover delays. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes.
To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010.
We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future.
On the 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The Plan focuses on improvements that will see the biggest impact on UEC performance next winter and on making UEC better every day, backed by a total of nearly £450 million of funding. The Plan will:
• Provide almost £450 million of capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances, avoiding unnecessary admissions to hospital and supporting the diagnosis, treatment and discharge on the same day for patients
• Reduce ambulance handovers to a maximum of 45 minutes, helping get 550,000 more ambulances back on the road for patients, and reduce Category 2 ambulance response time to 30 minutes
• Improve patient flow through hospitals, ensuring at least 78% of patients in A&E departments are seen within 4 hours and reduce the number of patients waiting over 12 hours for admission or discharge from an emergency department There is a national focus to improve Category 2 response time performance as these responses make up over half of all ambulance call outs and incidents within this category are of a high, lifethreatening nature. Improving Category 2 response times will improve ambulance performance generally, as more resources will then be available to attend lower acuity incidents. In May, average Category 2 ambulance response times were almost 5 minutes faster compared to the previous year, a reduction of 14.7%.
NHS England is working with systems to reduce ambulance handover delays, working towards delivering hospital handovers within 15 minutes with joint working arrangements that ensure no handover takes longer than 45 minutes. I recognise that this will be challenging in the South West, where handover delays have been much longer than this, but I am determined that we tackle these long delays across all areas. Nationally, in May 2025, average national handover times were 29 minutes and 30 seconds, an improvement of 2 minutes 44 seconds from the previous year.
In June 2025, we published our 10-Year Health Plan which sets out how we will reform the NHS, including urgent and emergency care services, with a key focus on shifting urgent care into the community through new Neighbourhood Health Services. The health plan focusses on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. I hope this response is helpful. Thank you once again for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 3 June 2025 sent to the Secretary of State for Health and Social Care regarding the death of Brian Garrick. I am replying as the Minister with responsibility for urgent and emergency care.
First, I would like to say how saddened I was to read of the circumstances of Mr Garrick’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.
Your report raises concerns over ambulance waiting times and ambulance handover delays. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS’s urgent and emergency care performance has been below the high standards that patients should expect in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes.
To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help deliver 40,000 extra appointments a week and cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010.
We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan-for-change), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future.
On the 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The Plan focuses on improvements that will see the biggest impact on UEC performance next winter and on making UEC better every day, backed by a total of nearly £450 million of funding. The Plan will:
• Provide almost £450 million of capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances, avoiding unnecessary admissions to hospital and supporting the diagnosis, treatment and discharge on the same day for patients
• Reduce ambulance handovers to a maximum of 45 minutes, helping get 550,000 more ambulances back on the road for patients, and reduce Category 2 ambulance response time to 30 minutes
• Improve patient flow through hospitals, ensuring at least 78% of patients in A&E departments are seen within 4 hours and reduce the number of patients waiting over 12 hours for admission or discharge from an emergency department There is a national focus to improve Category 2 response time performance as these responses make up over half of all ambulance call outs and incidents within this category are of a high, lifethreatening nature. Improving Category 2 response times will improve ambulance performance generally, as more resources will then be available to attend lower acuity incidents. In May, average Category 2 ambulance response times were almost 5 minutes faster compared to the previous year, a reduction of 14.7%.
NHS England is working with systems to reduce ambulance handover delays, working towards delivering hospital handovers within 15 minutes with joint working arrangements that ensure no handover takes longer than 45 minutes. I recognise that this will be challenging in the South West, where handover delays have been much longer than this, but I am determined that we tackle these long delays across all areas. Nationally, in May 2025, average national handover times were 29 minutes and 30 seconds, an improvement of 2 minutes 44 seconds from the previous year.
In June 2025, we published our 10-Year Health Plan which sets out how we will reform the NHS, including urgent and emergency care services, with a key focus on shifting urgent care into the community through new Neighbourhood Health Services. The health plan focusses on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. I hope this response is helpful. Thank you once again for bringing these concerns to my attention.
Report Sections
Investigation and Inquest
On 22 August 2022 I commenced an investigation into the death of Brian GARRICK. The investigation concluded at the end of the inquest on 16 April 2025. The conclusion of the inquest was; Cause of Death : 1a Acute Myocardial Infarction. II Ischaemic Heart Disease, Cerebrovascular Accident How, When and Where : Brian Garrick died at 1145 on 10 August 2022 at Derriford Hospital Plymouth as a result of an acute cardiac event against a background of long standing ischaemic heart disease. Narrative Conclusion : The Deceased started to experience acute cardiac symptoms of chest pain at 0130 on 10 August 2022. 999 was called at 0141 however an ambulance did not arrive until 0833 which was 5 hours later than normal service expectations. The Deceased was brought to hospital at 0945 and the cardiac procedure commenced within 32 minutes. The delay in the Deceased being brought to hospital by ambulance after the onset of acute symptoms contributed to his death.
Circumstances of the Death
Brain Garrick was a 75 year old man who suffered from ischaemic heart disease involving hardening and narrowing of his cardiac arteries. The condition had been monitored over the years and he had been issued with a GTN spray to alleviate symptoms of angina. At around 0130 in the early hours of 10 August 2022 Brian started to experience chest pains which were more severe than his previous experienced angina and were not alleviated by the GTN spray. An ambulance was called at 0141 which was given a category 2 response which was appropriate for Brian's presentation. Service level guidelines for the ambulance service required that 90% of responses to the patient should be within 40 minutes with a mean response time of 18 minutes. The ambulance arrived at 0833, nearly seven hours later, and conveyed Brian to hospital where he arrived at 0945. By 1012 Brian was undergoing a cardiovascular procedure to open a blockage which had been diagnosed in his left main stem artery. Sadly Brian suffered a cardiac arrest whilst the procedure was taking place and could not be resuscitated notwithstanding that the cardiac procedure was completed successfully. Brian was pronounced deceased at 1145 on 10 August 2022. I calculated that if the service requirement for response times had been achieved Brian would have reached the hospital by 0330. I heard evidence from the treating cardiologist that the chance of successfully treating Brian's acute condition reduced with each passing hour between the onset of symptoms and treatment. I accepted his evidence that had Brian been conveyed to the hospital by 0330 it is likely that he would have survived.
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Copies Sent To
2. South West Ambulance Service Trust
3. Plymouth University Hospitals NHS Trust
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.