Ricky O’Connell
PFD Report
All Responded
Ref: 2025-0433
All 1 response received
· Deadline: 15 Oct 2025
Response Status
Responses
1 of 1
56-Day Deadline
15 Oct 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. The inquest heard evidence that it was accepted that adherence to the timescales should have resulted in an ambulance arriving before he collapsed. The evidence given was that NWAS had done a huge amount of work to try to improve ambulance response times. This included improved staffing and call handling. However delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls including category 2 calls such as the one for Mr O’Connell.
2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services. The reasons for the demand were multi factorial and included challenges in accessing primary care.
3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further. On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances. This led to significant challenges for NWAS.
4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North West.
2. The inquest was told that the ambulance service was generally operating at full stretch due to the demand for their services. The reasons for the demand were multi factorial and included challenges in accessing primary care.
3. The inquest was told that generally the period towards the end of a nightshift could be the busiest and resulted in waiting times increasing further. On the day in question across GM some hospitals were taking up to 60 minutes extra over the accepted turnaround time to clear ambulances. This led to significant challenges for NWAS.
4. The inquest was told that in Greater Manchester all of the Trusts have improved their turnaround times overall in the last few months but due to very significant delays in ambulance turnaround times at other Trusts in particular in Cheshire and Merseyside, NWAS were still being adversely impacted in terms of available vehicles to respond to calls across the North West.
Responses
The Department references its June 2025 10-Year Health Plan and Urgent and Emergency Care Plan for 2025/26, which includes nearly £450 million in capital investment for emergency care and new ambulances. The response also highlights already achieved improvements in national and NWAS Category 2 ambulance response times and handover times between August 2024 and August 2025.
AI summary
View full response
Dear Ms Mutch,
Thank you for the Regulation 28 report dated 20 August addressed to the Secretary of State for Health and Social Care regarding the death of Ricky O’Connell. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to express my sincere condolences to Mr O’Connell’s family and loved ones. The circumstances described in your report are deeply concerning and I am grateful to you for bringing these matters to our attention.
Your report raises important concerns regarding ambulance response times and handover delays. In preparing this response, my officials have consulted NHS England (NHSE) and North West Ambulance Service (NWAS) to ensure your concerns are addressed thoroughly.
The Government is committed to ensuring patients receive the highest standard of care from the NHS. We acknowledge that the urgent and emergency care (UEC) performance has not consistently met expectations in recent years, and we are taking serious steps to address this. Building an NHS fit for the future is one of our five key missions.
In June 2025, we published our 10-Year Health Plan which sets out how reforms across the NHS, including UEC care services. The Plan outlines three major reform shifts:
• From hospital to community, bringing care closer to where people live
• From analogue to digital, modernising services through technology
• From sickness to prevention, helping people stay healthier for longer
We also published our Urgent and Emergency Care Plan for 2025/26 in June which focuses on improvements to deliver better UEC performance both daily and during winter pressures. Key actions include:
• Nearly £450 million of capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances
• Reducing ambulance handovers to a maximum of 45 minutes, and Category 2 response times to 30 minutes on average
• Improving patient flow through hospitals to 78% of patients seen in A&E departments within 4 hours and reducing 12-hour waits
NHSE continues to work closely with ambulance trusts including NWAS to improve Category 2 response times. You note there have been improvement in response times, which is reflected in the latest performance figures:
• In August 2025, the national average Category 2 response time was 27 minutes 3 seconds compared to 27 minutes 25 seconds in August last year.
• In NWAS, the average response time was 23 minutes 4 seconds, well ahead of the Government’s 30-minute recovery target.
Efforts to reduce ambulance handover delays are also progressing. NWAS reports significant local collaboration between Integrated Care Boards (ICBs), Acute Trusts, and NHSE regional teams. These efforts aim to ensure safe and timely patient handovers, freeing up crews to respond to emergencies in the community.
• NWAS’s average handover time has improved from 26 minutes 24 seconds in August 2024 to 22 minutes 35 seconds in August 2025.
• Their 90th centile handover time has also improved from 45 minutes 54 seconds to 39 minutes 4 seconds over the same period.
We will continue to monitor performance closely and work with NWAS and NHSE to ensure sustained improvement. I hope this response provides reassurance that the Government is taking meaningful action to improve urgent and emergency care services. Thank you once again for raising these concerns.
Thank you for the Regulation 28 report dated 20 August addressed to the Secretary of State for Health and Social Care regarding the death of Ricky O’Connell. I am replying as the Minister with responsibility for urgent and emergency care.
Firstly, I would like to express my sincere condolences to Mr O’Connell’s family and loved ones. The circumstances described in your report are deeply concerning and I am grateful to you for bringing these matters to our attention.
Your report raises important concerns regarding ambulance response times and handover delays. In preparing this response, my officials have consulted NHS England (NHSE) and North West Ambulance Service (NWAS) to ensure your concerns are addressed thoroughly.
The Government is committed to ensuring patients receive the highest standard of care from the NHS. We acknowledge that the urgent and emergency care (UEC) performance has not consistently met expectations in recent years, and we are taking serious steps to address this. Building an NHS fit for the future is one of our five key missions.
In June 2025, we published our 10-Year Health Plan which sets out how reforms across the NHS, including UEC care services. The Plan outlines three major reform shifts:
• From hospital to community, bringing care closer to where people live
• From analogue to digital, modernising services through technology
• From sickness to prevention, helping people stay healthier for longer
We also published our Urgent and Emergency Care Plan for 2025/26 in June which focuses on improvements to deliver better UEC performance both daily and during winter pressures. Key actions include:
• Nearly £450 million of capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances
• Reducing ambulance handovers to a maximum of 45 minutes, and Category 2 response times to 30 minutes on average
• Improving patient flow through hospitals to 78% of patients seen in A&E departments within 4 hours and reducing 12-hour waits
NHSE continues to work closely with ambulance trusts including NWAS to improve Category 2 response times. You note there have been improvement in response times, which is reflected in the latest performance figures:
• In August 2025, the national average Category 2 response time was 27 minutes 3 seconds compared to 27 minutes 25 seconds in August last year.
• In NWAS, the average response time was 23 minutes 4 seconds, well ahead of the Government’s 30-minute recovery target.
Efforts to reduce ambulance handover delays are also progressing. NWAS reports significant local collaboration between Integrated Care Boards (ICBs), Acute Trusts, and NHSE regional teams. These efforts aim to ensure safe and timely patient handovers, freeing up crews to respond to emergencies in the community.
• NWAS’s average handover time has improved from 26 minutes 24 seconds in August 2024 to 22 minutes 35 seconds in August 2025.
• Their 90th centile handover time has also improved from 45 minutes 54 seconds to 39 minutes 4 seconds over the same period.
We will continue to monitor performance closely and work with NWAS and NHSE to ensure sustained improvement. I hope this response provides reassurance that the Government is taking meaningful action to improve urgent and emergency care services. Thank you once again for raising these concerns.
Report Sections
Investigation and Inquest
On 3rd February 2025 I commenced an investigation into the death of Ricky O'CONNELL .The investigation concluded on the 2nd July 2025 and the conclusion was one of narrative: Died from acute myocardial ischaemia in the context of a significant delay in an ambulance attending following a 999 call. The medical cause of death was 1a) Acute Myocardial Ischaemia 1b) Coronary Atherosclerosis
Circumstances of the Death
Ricky O'Connell's partner called for an ambulance at 05:44 when his overnight symptoms deteriorated and he was concerned he was having a heart attack. He was categorised as a category 2 call. On the Department of Health Standards that should result in an ambulance on average arriving within 18 minutes and in 9 out of 10 cases within 40 minutes. The ambulance had not arrived by 06:38 due to very significant delays across the North West, primarily due to prolonged hospital handovers and overall demand on the service. His partner called again. At 06:43 during that call he collapsed and the call was upgraded to Category 1. An Ambulance was dispatched (the earlier call was still in the queue for dispatch). CPR was given by his family and then the ambulance and he was transported to Tameside General Hospital where attempts to resuscitate him continued. He died at Tameside General Hospital on 27th January 2025.
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.