Inquests are a fact inquiry into a person's death and it is important that lessons are learnt: The making of this report is not punitive nor is it a censure. However; it is the 2"d such Report in recent months that I have written about the timely despatch and arrival of an ambulance crew in response to a 999 call [heard evidence about the reviews of procedures undertaken since Andrew' s death; but [ still have concerns_ Although the plans for the recruitment and retention of personnel and the purchase of additional vehicles were encouraging to hear evidence about; [ was told there were still 32 paramedic vacancies to be filled a year on after Andrew' $ death. For Andrew the made no difference, but for someone else it might: Accordingly it is my to write this Report to you, particularly as it may add impetus to the improvement plan_