The death of a motorcyclist who had to wait almost an hour for a paramedic to attend the scene of an accident contributed to neglect of the ambulance service, a coroner has ruled.

Father-of-five Aaron Morris suffered a cardiac arrest in an ambulance his wife Samantha was taking to hospital because the driver did not know the way, an inquest in Crook, Co Durham, was told.

Mr Morris, 31, died at University Hospital of North Durham on July 1, 2022 at 6.40pm after an accident which happened around six hours earlier in Esh Winning.

His wife, pregnant with twins at the time, was returning from a hospital appointment when she came upon the scene of the accident, where her husband’s Honda motorcycle had collided with a car at an intersection.

During the inquest Coroner Crispin Oliver was told it took 54 minutes for an ambulance to arrive at the scene due to high demand.

Mr Oliver heard during the inquest that an expert rated Mr Morris’s chances of survival at 95 per cent if he had been treated in time.

The coroner also heard that an air ambulance could have been sent to the scene earlier but this did not happen.

Mr Oliver was also told that a specialist paramedic known as a clinical team leader (CTL) should have gone to the scene but she did not leave a meeting which was being held at Stanley.

The coroner said: “It is very likely that Aaron Morris would have survived if the specialist medical treatment available had been applied in time.

“Which did not happen due to a) the delay in allocating an ambulance deployed to the scene due to over-resourcing and b) the CTL ambulance service not being on the scene at 12.52pm when there was certainly enough information for it. so.”

Mr Oliver concluded: “Aaron Morris died as a result of injuries sustained in a road traffic collision and the negligent failure of the ambulance service to respond.”

A private ambulance, driven by Ambulance, was the first to arrive at the scene, the inquest heard.

Mr Morris died from chest injuries sustained in the crash, after which he was conscious and breathing but in severe pain.

Mr Oliver said two experts found there was a critical moment before Mr Morris’s cardiac arrest in the ambulance, before which he would likely have survived if the correct medical intervention had been available.

The coroner said witnesses from the institutions involved in the inquest had behaved in a “humane” manner at hearings and the organizations involved “appeared considerably chastened by their own review of the circumstances of what happened”.

Outside the hearing, Ms Morris said she welcomed the improvements made by the North East Ambulance Service and the Great North Air Ambulance Service (GNAAS).

She said: “The transparency and proactive approach of NEAS and GNAAS is appreciated and I am glad that lessons have been learned.

“Changes have already been implemented to prevent other families going through such a horrific experience.

“They gave me support before, during and after the investigation and we had open discussions about how the new trauma office was working and the organizational changes that had been made.

“After hearing the evidence from Dr. Noble, the medical director of NEAS, about preventing future deaths, I would now feel confident dialing 999 and requesting a North East Ambulance, which I never thought I would say.

“I have no doubt that if GNAAS had attended, the skills and expertise of their paramedics would have saved Aaron’s life.

“We are lucky to have such a charity in our region.”

She added: “For almost two and a half years, I have been focused on finding answers to why Aaron died and this investigation.

“I spent a lot of that time in hospital with my twin boys, who were born prematurely and have had a lot of medical treatment since then.

Laura Gabbey-Cristofini, fatal accident solicitor at Irwin Mitchell, representing Mr Morris’s family, said: “The last two years and trying to come to terms with Aaron’s tragic death have been incredibly difficult for Samantha.

“Her pain was compounded by the many unanswered questions and concerns she had about the events that unfolded.”

Dr Kat Noble, medical director of the North East Ambulance Service, said: “Firstly, I would like to say to Samantha and all of Aaron’s family that I am deeply sorry.

“When concerns were raised about Aaron’s care, we reported them as a serious incident and undertook a thorough investigation into what happened.

“We have shared the outcome of the serious investigation with Aaron’s family.

“There were a number of organizations involved in this case and we apologize unreservedly for not providing the right care from our service when Aaron needed it.

“We accept that opportunities to send a clinical team leader to this incident were missed.

“This is the responsibility of teams monitoring incoming and changing information about a patient’s condition, rather than a single responder, and we have made changes to our implementation processes to ensure this cannot happen again.

“There have been a number of other actions arising from the review of this incident that we have taken to improve the co-ordination of our response and we fully accept the coroner’s findings and conclusion.”