Overview
- Peter Coates, 62, was found dead 47 minutes after calling 999 when a power outage disabled his mains-powered oxygen on March 14, 2019.
- The first ambulance could not leave its station because electronic gates failed during the blackout and the crew lacked manual override training.
- A second ambulance was reassigned but stopped to refuel under NEAS guidance to keep tanks above half full, a process that took just over four minutes.
- On arrival, crews initially could not find the key safe to enter the property, and the approximate location was not included in the crew notes.
- NEAS apologised and said it has updated training and processes, including gate override instruction and iPads for fuller notes, as the family welcomed the finding but criticised the long wait for answers.