Man found dead morning after being wrongly told an ambulance was on its way

PLUS: Reform UK's Preston claims under the microscope again

Luke Beardsworth

The Lancashire Lead

, and

Michael Holmes

Apr 23, 2025

∙ Paid

Hello and welcome to The Lancashire Lead.

Today we report on the death of a young man whose friend was told an ambulance was on its way. When it eventually arrived the next morning, the man was found dead.

It’s prompted a strongly-worded letter from the coroner for Lancashire and Blackburn with Darwen saying that the same thing could happen again unless changes and improvements are made.

We also report on a Reform UK candidate who posted ‘unconfirmed’ reports that a closing care home in Preston was going to be used to house asylum seekers.

Although the candidate claimed he was doing ‘some actual journalism’ in asking important questions, it’s not clear what efforts were made to verify the claim before posting. This journalist was able to confirm that there were no such plans inside 30 minutes on Easter Sunday.

Ambulance service forced to apologise after man left suicidal at home

By Michael Holmes

A good Samaritan who called 999 after his suicidal friend self-harmed inadvertently left him to die after wrongly being told an ambulance was en route, an inquest has been told.

James Paul Michael Masheter’s friends rallied around him after he called them to say he was “dying”, with one concerned pal turning up at the 42-year-old’s home in Hoyles Lane, Cottam, to help look after him until professional help arrived.

Preston-born Masheter, who had a history of ill mental health and self-harming, and who had been through a recent break-up and was having money troubles, was distressed and bleeding from superficial wounds on March 31 2024.

Four 999 calls were made that evening - with the unnamed friend leaving after being told an ambulance would be there “imminently”, a hearing held to establish the circumstances of Masheter’s death was told.

But the waiting time information was incorrect and no ambulance actually arrived until 8.10am the next day, with its crew finding Masheter dead inside his home.

The telecommunications engineer died from hanging, post-mortem tests concluded.

Kate Bisset, coroner for Lancashire and Blackburn with Darwen, has now written to bosses at NHS England to tell of her concerns.

In her letter, which was also sent to the North West Ambulance Service (NWAS), which has apologised, and Masheter’s family, she writes: “Due to demands of the service, there were significant delays in ambulance allocation but Mr Masheter’s friend was told that that delay was significantly less than was the case.

“Incorrect information about the waiting times for ambulance attendance was provided to Mr Masheter’s friend and this contributed to his death.”

Bisset specifically criticised the NHS Pathways system used to triage patients.

The pathway sees emergency service operators ask scripted questions to determine the seriousness of a call, including whether the patient is awake and breathing.

But questions for mental health calls are “limited”, the coroner said, adding that it is “not clear” to her “whether it is possible for serious mental health crisis situations which present a risk to life (to be) capable of being properly risk assessed on the basis of the NHS Pathways mental health triage which exists at present”.

Masheter was treated as a category three patient on each of the four times the ambulance service was contacted on the eve of his death. The “urgent” categorisation means paramedics should arrive on the scene within 120 minutes “at least nine out of 10 times”.

There are four categories, including:

One, for life-threatening injuries and illnesses, with an average response time target of seven minutes and within 15 minutes nine in 10 times;
Two, for emergency calls, with an average response time target of 18 minutes and within 40 minutes nine in 10 times; and
Four, for less urgent calls, with a response time target of within 180 minutes at least nine in 10 times, though callers may instead be given telephone advice or referred to another service such as a GP or pharmacist.

While Bisset’s report does not say when exactly each 999 call was made in Masheter’s case, timings suggest it took more than eight hours for an ambulance to turn up.

NHS England has until May 30 to respond to Bisset’s letter. It must say what action it has taken or will take - or explain why nothing will be done.

Masheter’s funeral was held at St Andrew & Blessed George Haydock Catholic Church in Cottam on April 19 last year, followed by a wake at the Lonsdale Social Club in Preston.

An online obituary includes a photograph that appears to show him raising his arms in victory inside a boxing ring. The announcement includes the words: “Loving you always, forgetting you never.”

Donations to the Mary O’Gara Foundation, a suicide prevention, awareness and education charity based in Fulwood, were being accepted in lieu of flowers.

NWAS and NHS England were contacted for a comment.

An NWAS spokesperson said: “We offer our sincere condolences to James’s family and apologise for not responding to him quickly enough.

“We have carried out our internal investigation and will now review the regulation response in light of the coroner’s concerns.”

NHS England did not respond by the time of publication.

The Lancashire Lead contacted Dignity Funeral Directors, which announced Masheter’s death, in a bid to contact his family prior to publication.

NWAS bosses heard concerns about the “algorithm from the triage tool” at the service’s last board meeting.

It followed a complaint from Stella, the daughter of a patient, who called NHS 111 when her elderly mother was “feeling ill and had all the signs of a chest infection”.

Stella, an ex-nurse, called NHS 111 on a Sunday to ask for a prescription for antibiotics but was instead told an ambulance was needed.

“Despite Stella’s experience as a retired nurse, and her request for antibiotics for her mother’s chest infection, the algorithm from the triage tool put this presentation to mean that there was a risk of sepsis and so triggered an ambulance response instead of the antibiotic prescription which she wanted,” ambulance service papers said.

“Stella felt that her experience and knowledge should have been considered by the call-taker and by speaking to a fellow health professional she could explain the rationale behind needing the prescription and to avoid a hospital attendance, which she thought would be detrimental to her mother’s condition.”

A review of the 999 assessment and triage system was launched after the death of 17-year-old footballer Adam Ankers, who collapsed while leaving the pitch after playing for Wycombe Wanderers’ U19s in January 2024.

A 999 call handler, according to reports in the national media, failed to spot a red flag symptom of a cardiac arrest and instead followed guidance for treating a seizure.

It meant CPR was not started until half an hour later by paramedics.

It was not the first time NHS Pathways had problems with irregular breathing patterns, with the Health Service Journal reporting in 2019 that there were six cases where concerns had been raised, including two where coroners issued reports similar to the one written by Bisset after Masheter’s death.

The NWAS meeting, held at the end of March, also looked at the latest available performance figures, including ambulance response times, which continued to be “challenged”, documents admitted.

The average year-to-date category one response time was 7 minutes and 47 seconds, worse than a target of seven minutes.

The average year-to-date category two response time was 30 minutes and 12 seconds, against a target of 18 minutes.

And the average year-to-date category three response time was 119 minutes and 39 seconds, almost double the target of one hour.

NWAS is not the only ambulance service struggling to hit the response time targets.

The average response time in March for ambulances in England dealing with the most urgent incidents was seven minutes and 52 seconds, it was revealed in April.

This was down from eight minutes and four seconds in February and the fastest time since May 2021, but above the target standard response time of seven minutes.

Meanwhile, ambulances took an average of 28 minutes and 34 seconds in March to respond to emergency calls such as heart attacks, strokes and sepsis.

This was down from 31 minutes and 22 seconds in February.

The government and NHS England have set a new target for this figure to average 30 minutes across 2025/26.

Professor Sir Stephen Powis, national medical director at NHS England, said: “Despite services facing the busiest March ever in A&E and for ambulance incidents, staff continue to bring down waits for urgent and emergency care.

“But we know there is much more to do to reduce waits and delays across all NHS services.”

Francesca Cavallaro, senior analytical manager at the Health Foundation, said: “The winter has yet again exposed the huge impact on people using an overstretched health and care system.

“The upcoming 10-year health plan must aim to build an NHS which can keep people well and out of hospital.”

Reform UK candidate under fire for ‘completely unfounded’ claims and ‘inappropriate’ campaigning

By Luke Beardsworth & Ed Walker

Parker argues with staff at the egg-rolling

A Reform UK candidate has drawn criticism in the last week for 'unfounded and misleading’ speculation about asylum seekers and ‘inappropriate’ campaign locations.

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