On 25 May 2023 I commenced an investigation into the death of Shaun PARKS. The investigation concluded at the end of the inquest on 15 December 2023. The conclusion of the inquest was that Mr Parks died on 13 December 2022 at the Northern General Hospital in Sheffield, there was a significant delay in Mr Parks receiving treatment and this may have affected the outcome. His medical cause of death was recorded as: 1a Myocardial infarction (stented) 1b Ischaemic heart disease.

Mr Parks attended Doncaster Royal Infirmary's Emergency Department on 12 December 2022 at roughly midnight, Mr Park's waited in the emergency department for approximately 1-1.30 hours until an ECG was carried out and showed Mr Parks to be suffering a heart attack. Mr Parks was moved to the resuscitation area of the department and an interfacility transfer request to the Northern General Hospital's primary percutaneous coronary intervention (PPCI) centre was made by a nurse at the hospital to Yorkshire Ambulance Service (YAS). It was confirmed by YAS that the category 2 blue light ambulance was booked at 3.06am on 13 December 2022, the ambulance should have taken at the latest 40 minutes to arrive, YAS confirmed the ambulance was categorised correctly as a category 2. The ambulance arrived at Doncaster Royal Infirmary at 06.29 hours and left scene to transfer to Sheffield's Northern General

Hospital's PPCI 06.44 and arrived at 07.15. Mr Parks deteriorated during his time at Doncaster Royal Infirmary and his procedure at Sheffield's PPCI unit commenced at 08.45. Mr Parks sadly died during the procedure at 10.17. There was a delay in the ambulance arriving to collect Mr Parks of 3 hours 18 minutes and 41 seconds.