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The family of a former steelworker are calling for an inquest into his death in the light of a report into the North East Ambulance Service.
The case of Peter Coates formed part of an independent review into allegations that the service had covered up serious errors by altering or omitting details given to families and coroners.
The report, published on 12 July 2023, catalogued a series of delays in reaching Mr Coates after he called 999 and found that had crews arrived earlier, he may not have died.
Mr Coates, from Redcar, lived with the lung disease COPD and relied on a constant supply of oxygen.
He made an emergency call on 19 March 2019 after a power cut interrupted the supply, which needed electricity to operate.
A first ambulance crew was trapped inside the ambulance compound, just a few minutes from Mr Coates' home, because the gates were affected by the same power outage, with no one able to manually override them.
A second crew made an unnecessary stop for fuel.
That crew then struggled to locate a safe box outside Mr Coates' home, which contained door keys, delaying their entry by almost 12 minutes.
Mr Coates family were not originally told about these issues, and only became aware of them in 2022.
The 62-year-old's daughter Kellie Coates told ITV Tyne Tees: "We've already done our grieving for our father when he died so to find out, three years later, the circumstances around his death and the fact that he could still be with us now if it wasn't for those service failings, was really upsetting and frustrating."
Mr Coates' call to 999 had been classed as a 'category 2'.
As such, the second ambulance crew arrived with Mr Coates just within the national target time of 40 minutes.
That meant it was not treated as a serious incident and NEAS did not - at first - tell the coroner about the delays.
The independent review, led by Dame Marianne Griffiths, concluded that had an ambulance arrived earlier, Mr Coates may not have deteriorated so quickly and died.
Now, Ms Coates and her five brothers are calling for an inquest.
Ms Coates said it was important to the family that her father's death certificate reflects the full circumstances.
She told us: "We have a duty as a family to make sure that shows exactly how he left this world so we can share that with his grandchildren", adding: "It's about having the truth."
The family are also joining wider calls for a public inquiry into the North East Ambulance Service failings.
Ms Coates said such an inquiry would allow further scrutiny of issues which had come to light.
Responding to the review published on 12 July, NEAS chief executive Helen Ray offered an unreserved apology on behalf of the trust.
She acknowledged "flaws" in processes and said a number of measures had already being implemented to ensure the issues do not happen again.
Others, she said, were being introduced "at pace."
In a statement for ITV Tyne Tees, responding specifically to the family of Peter Coates, she said: “Firstly, I would like to reiterate how sorry I am for any distress caused to Mr Coates' family for mistakes made in the past.
"The decision to hold an inquest is a matter for the coroner and we would clearly fully cooperate with any further inquiries, especially if it brings comfort to Peter’s family in this tragic case.”
A letter from the family requesting an inquest is expected to be received by the Teesside senior coroner in the coming days.
ITV Tyne Tees understands that the coroner's office intend to speak directly with Mr Coates' family.
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