Paramedics took 13 hours to reach the home of a man attempting suicide, then spent half an hour waiting outside before realising his door was unlocked, an inquest heard.

Ambulance service staff called police to help them gain entry to John Robert Taylor’s home but hadn’t tried the door handle. If they did, they would have realised the door was unlocked and given him treatment sooner.

An inquest at Teesside Coroners Court earlier this month heard Mr Taylor overdosed on July 18 last year with the intention of ending his life.

He later rang the fire service for help, who alerted police and called for paramedics to attend just before 4pm that day.

But an ambulance didn’t arrive until just after 5.23am the next day (July 19, 2022), more than 13 hours later.

Paramedics tried the door but received no reply and called for police back up. When officers arrived they found the door was unlocked and were inside within a minute.

John was still alive and taken to University Hospital North Tees, where he tragically died he died a week later on July 27, 2022.

Senior Coroner Clare Bailey said his death “was contributed to by the delay in the arrival of the ambulance”.

The North East Ambulance Service (NEAS) carried out a serious incident review, but the clinical section manager who wrote the report was not told the door to the property was unlocked and that paramedics could have been at John’s side half an hour earlier.

The ambulance service apologised to his family and said it would learn from the incident.

The coroner said she was concerned the information was not ‘offered, elicited or reported’ to the manager carrying out the internal investigation.

Miss Bailey said: “In my opinion, there is a risk that future deaths could occur unless action is taken.”

Filing a report into his death she outlined three matters of concern – that paramedics ‘had not adequately checked the door handle’, that this information was not known by the internal investigation, and that consideration was not given to the possibility of sending a taxi to Mr Taylor to get him to hospital sooner.

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His family told the inquest the ambulance service had previously booked John a taxi to hospital on several occasions, but this was not considered on the day he called for help.

Director of quality and safety at NEAS Julia Young said: “I would like to add my condolences to Mr Taylor’s family and friends. This is a tragic case and we are sorry that we were unable to reach Mr Taylor sooner.

“At the time of his call, we were operating at our highest level of escalation due to severe pressures on our service as a result of delays handing over patients at hospital.

“We reported this case as a serious incident, completed an investigation into Mr Taylor’s care and have implemented the learning from this case to improve our response to patients experiencing a long wait. We also continue to work with our NHS partners to significantly reduce handover delays.  

“We will be responding to the coroner directly with the concerns raised in her report once we’ve had a chance to review the evidence that emerged during the inquest hearing.”

The ambulance service is required to respond to the concerns by February 9, 2024.

If you are in need of support you can contact the following:

- Samaritans is available, day or night, 365 days of the year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

- If U Care Share on 0191 387 5661 or text IUCS to 85258

- SANE on 07984 967 708, Calm on 0800 58 58 58

- Tees, Esk and Wear Valleys NHS Foundation Trust crisis line 0800 0516 171.