A Croydon man was found on a park bench and later died suffering from Covid-19 after an eight-hour wait for help at the start of the pandemic.

Richard Boateng, 23, tragically died from coronavirus at Croydon University on March 31 last year after mistakes and ambulance shortages meant he was barely able to speak by the time emergency service responded.

Following the inquest into his death, a coroner has now called for national changes to prevent future deaths from happening.

Jonathan Landau, assistant coroner for South London, said in his Report To Prevent Future Deaths that Richard had called his GP surgery feeling “very unwell” on March 30, 2020 but was only offered a routine appointment by a receptionist.

By the time he was called back by a GP the next morning (March 31 2020) he was unable to complete sentences or give his full name.

Your Local Guardian: PA WirePA Wire

The GP called an ambulance, but Richard was not at home and paramedics told his sister to call the police.

The 23-year-old was later found on a bench by police officers at around 4pm, and a second ambilance didn't arrive until 6:23pm.

Richard had been on the bench in the street from at least 10.30am that day, and despite being taken to Croydon University Hospital, he died that evening after attempts to resuscitate him.

An investigation into Richard's death began on August 19, 2020, and the inquest ended on September 24, 2021.

Coroner Jonathan Landau opted to published a prevention of future deaths report, in which he lays out his concerns and says there is a risk future deaths could happen without action.

It was sent to NHS England, London Ambulance Service (LAS) and the College of Policing which all have 56 days to respond.

In the report, the coroner says a call to the GP surgery the day before Richard's death was taken by a receptionist who was not a qualified clinician.

The surgery has since introduced a new system called Klinic which is judged to be safer, prompting questions and alerting urgent calls when flagged.

About NHS England, the coroner wrote: “However, I am concerned that other surgeries may employ non-clinicians who may be required to make judgements as to the urgency of appointments, and there is no guidance available to surgeries as to how to mitigate the risks of this.”

In relation to the LAS, Mr Landau said that in this case it would have been better for the paramedic to take the sister’s number and pass it on to police. He says guidance to ambulance crews needs to be updated to reflect this.

Due to the pandemic, there were no ambulances available when police located Richard, and Met Police had a policy that officers could take patients to hospital if no ambulances were available.

But Mr Landau says there was “no practical guidance” about how this could be done.

He wrote: “I heard that the Metropolitan Police Service is updating the guidance.

“However, I am concerned that other forces across the country may also lack such practical guidance, which is of particular concern due to the ongoing pandemic and the demands that may continue of ambulance services.”

An NHS spokesperson said: “The NHS sends sincere condolences to the family affected and will respond in the usual way within the time frame set by the coroner.

“Individual GP practices are responsible for training their staff in patient triage and assessment systems.”

“Individual GP practices are responsible for training their staff in patient triage and assessment systems.”

A spokesperson for Metropolitan Police said: “The death of Mr Boateng was a dreadful incident and the thoughts of the Met are with his family and friends.

“In relation to the case of Mr Boateng and if he should be transported in a police vehicle, the decision was dynamic and remained under constant review."

They added that no criticism was made of the actions of officers who attended and later explained their actions rationally at the inquest.

You can read the coroner's report to prevent future deaths here.