According to the inquiry, a paramedic was at a meeting when she had the opportunity to assist a dying motorcycle father of five who died after waiting for treatment for 54 minutes.

A professional doctor, known as a Clinical Team Leader (CTL), was stationed in Stanley, about 9.1 miles away at the time of the crash, and could have attended, according to NEAS.

Which Aaron’s family and the coroner have commended for its openness and truthfulness throughout the inquiry.

But when a colleague asked whether CTL Sarah Hall was available, she wasn’t sent to the site since she was at a meeting she didn’t need to be in.