Hertfordshire man died after six-hour ambulance delay
Paul Burke, 41, died after waiting more than six hours for an ambulance, prompting a coroner to warn that delays in emergency care continue to put lives at risk
Hertfordshire's coroner is demanding urgent changes after a man was left waiting more than six hours for an ambulance that never arrived, and died. The incident has led to a formal warning from Hertfordshire’s area coroner about ongoing risks to life across the country due to ambulance delays.
The coroner, Jacques Howell, raised his concerns in a report following the conclusion of an inquest into the death of 41-year-old Paul Burke, on 2 May 2025.
Mr Burke first called 999 on 19 December 2022 at 14:07, reporting severe shortness of breath. His condition was classified as a Category 2 emergency, which should have meant a response within 18 minutes on average, and within 40 minutes in 90% of cases. However, no ambulance arrived.
Despite repeated calls to the ambulance service over the next six hours, including at 14:59, 16:31 and 19:09, no paramedic team was sent. Eventually, Mr Burke's family took him to Watford General Hospital by car at 20:16. He arrived shortly before 21:00.
A blood test at the hospital showed Mr Burke was suffering from Type 2 respiratory failure. He was moved to the resuscitation area, but several clinicians did not act on the result and instead treated him for fluid overload linked to heart failure. Mr Burke’s known medical history of obesity hypoventilation syndrome was not fully considered.
His condition worsened the following night. More tests confirmed the severity of his respiratory failure, and he was moved to the Acute Respiratory Care Unit and placed on non-invasive ventilation. However, he continued to deteriorate and died at 07:44 on 22 December 2022.
The inquest concluded on 25 April 2025. The cause of death was recorded as Type 2 respiratory failure, with obesity hypoventilation syndrome and heart failure contributing. The coroner found that the ambulance delay likely had only a minimal impact on Mr Burke's death in this particular case, but warned that similar delays pose a serious ongoing risk.
In the report, Mr Howell said: “Despite the urgency with which an ambulance was required for Mr Burke, no ambulance resource was available. It was only due to the intervention of his family... that he was able to get to hospital – others may not be so fortunate.”
On the day Mr Burke called for help, the East of England Ambulance Service had 243 Category 2 calls outstanding at 14:40, with 37 in the Hertfordshire area. By 18:01, this had risen to 315 calls, including 47 in Hertfordshire. Several ambulances were delayed at Watford General Hospital, including one waiting more than five hours to hand over a patient.
Coroner Howell noted that these pressures were not unique to that day or location. He cited national data showing that in December 2022, the average Category 2 response time was 61 minutes. In December 2023, it rose to 125 minutes, before falling to 50 minutes in December 2024 – still far above the 18-minute target.
In his report, sent to the Secretary of State for Health and Social Care, Mr Howell wrote: “There is a risk of future deaths occurring due to continuing delays in the provision of pre-hospital emergency care which appear to be multi-factorial in nature.”
He has requested a formal response by 27 June 2025, outlining what action will be taken to prevent future deaths.