Overview
- An ambulance crew minutes away from Peter Coates was unable to leave Redcar station because electric gates failed, and the case was not reallocated for about ten minutes.
- The second crew stopped to refuel despite having around 29 litres on board, with witnesses describing past practices and updated rules now requiring crews to refuel before being assigned.
- Paramedics said the key-safe location was not passed in crew notes, costing roughly ten minutes to gain entry before Coates was found dead attached to a portable oxygen cylinder.
- Expert evidence said loss of oxygen was the key factor in Coates’ death, though the exact time of death could not be determined and a pathologist questioned reports of early rigor mortis.
- A former NEAS head of patient safety downgraded the incident’s harm level, which avoided a serious incident probe and duty-of-candour notification to the family; the inquest has been adjourned to allow final submissions in February or March.