On 14/12/12 commenced an investigation into the death of Martin investigation concluded at end of the inquest on 05/09/13. The Daffydd Barker: The orquesdwes that the deceased died as a resuit of MDMA toxicity conclusion of the of Misadventure. and recorded a verdict

On the 9th December 2012 the deceased was on the Warehouse Project in Trafford which is night out with friends. attended between September a venue which runs events on weekends venweeat esteries andrinnune cOthere are approximately 5000 peopie whoeateeng the drug ecstasy During eheecourse %f the evening the deceaseopook/a qudenty t€e site at the (MDMA): iHe became unwell and was taken to the medical Gervices on venue_ This Service is run by Manchester Medical Services as requiring emergency admission t0 hospitac and evaseaken He was assessed Services in their ambuiance to Salford by Manchester Medical he was pronounced deceased at Salford Hospital Despite attempts at resuscitation 1a) MDMA toxicity. Royal. His cause of death was confirmed as Folpitan9On aravers death concerns were raised by the Resus Unit at Salford Hospital: On arrival at the hospital Mr Barker was in cardiac Royal team had not received a prior warning that the ambulance arrest, however Resus and therefore were not expecting them and was en route to the hospital telephone number within were not prepared and on standby; There is regional ambulance the hospital Resus Department which is allocated to the service, in this case North West Ambulance Service aho i entrouteiwith a patient can call to notify the hospital s0 that are anticipating their arrival and the patient is categorised can be ready according to their seriousness as either a 'Red' or 'Amber' Iaddition in this case, at 3am (which was the time Mr Barker Resus Reception Desk is not always staffed as the arrived at the hospital) the which take her away from the desk The entranceetoeRegtionssthrauother_responsibilities ambulance which has a locked to Resus is through a door from the arrest_the receptionist keypad. At the point Mr Barker arrived in cardiac was not at her desk_and Manchester Medical Services ' did not the They the Royal the they they category bay have the keypad code in order t0 access the door: On this occasion security staff happened to be passing and were able to assist in gaining entry: Manchester Medical Services are one of a growing number of independent medical providers. They are contracted to provide medical cover at large events, approximately 900 per year throughout the UK Many of the events involve in excess of 10,000 people. They have as part of their medical cover ambulances to transport people to hospital should this be required: At the Inquest heard evidence from Salford Royal Hospital, Manchester Medical Services and North West Ambulance Service. All confirmed in evidence to me that this was potentially a national problem and that there was no clear guidance or policy in place nationally or locally Salford Royal indicated that it was their understanding from event planning meetings which had taken place in 2011 around the Manchester Pride event that the position was that independent providers such as Manchester Medical Services should, if are on the way to hospital with a critical patient; ring North West Ambulance Services who would then telephone the relevant hospital and notify them of the impending arrival. It was clear that up to present there has been a refusal t0 provide independent providers with the telephone number s0 that they can use this directly. It was somewhat unclear whether this refusal t0 disclose the number was by the NHS Trusts or North West Ambulance Service. There were understandable concerns that the number should be used appropriately and that there should be a uniform approach to classifying patients as 'Red' or Amber' (this simply North West Ambulance Service classification ) The Director of Manchester Medical Services gave evidence and indicated that this issue is raised by them at planning meeting attend for major events. However they are consistently refused the alert telephone number: It was also the understanding of Manchester Medical Services that despite previous discussions North West Ambulance Service will not act as an intermediary t0 place the pre-alert call through to the relevant NHS Trust as the independent ambulances are not on the NWAS system: He indicated in evidence that the only time NWAS will place a pre-alert call is if they have their own crews at an event together with the independent providers and a member of NWAS places the call into their operators. Since this incident Manchester Medical Services have made further attempts to obtain the pre alert telephone number t0 no avail. He also confirmed that an ideal situation would be not to involve NWAS but for them to be able to use the number directly: Angela Lee; Sector Manager for NWAS, then gave evidence and she indicated that it was her understanding that NWAS would act as an intermediary for the independent medical providers to place calls through to NHS Trusts to alert them and that NWAS would not want the telephone number directly provided to other medical service providers, although she could not explain the rationale for this also indicated that she would expect NWAS to then triage the patients over the telephone in accordance with NWAS policies and to categorise them in line with NWAS categorisations. This was somewhat surprising given that NWAS will not have any contact with the patient and are in no way involved in their transportation to hospital: What was agreed by all who gave evidence was that there are no written policies locally or nationally and that all would be greatly assisted by the same

In my opinion there should be local if not national written policies as to how NHS Trusts are placed on pre-alert by independent medical providers and this should be clearly distributed to all concerned as a matter of urgency: