Leeds United fan Josh Edwards, 19, of Bramley suffered a fatal reaction to ecstasy and cocaine and died in hospital after suffering a fitting episode on a Leeds street on Sunday May 14 2017.
His inquest on Monday (Oct 1) at Wakefield Coroner’s Court heard ambulance crews took longer to arrive at the scene on Victoria Park Avenue in Bramley because they avoided roads closed on the half marathon route.
The inquest heard they were allowed to cross ‘road closure’ signs in an emergency, but were unclear as to whether or not they could.
Senior Coroner Mr McLoughlin today (Weds Oct 3) said he has written to all emergency services and Leeds City Council calling for a number of measures to be introduced at events including road closure signs being replaced with ‘access to emergency vehicles only signs.’
Mr McLoughlin states in the report to prevent future deaths: "An ambulance was called at 12.19pm but did not arrive until 12.44pm."
Mr McLouglin wrote: “Evidence taken at the inquest indicated that ambulance crews were unclear as to whether they were entitled to cross ‘road closure’ signs in an emergency.
“Clarification of the ambulance service authority to do so in an emergency has been given, but has not yet been circulated to all ambulance crews.”
Mr McLoughlin said event organisers should brief marshalls that at specified cross points an emergency may take precedence and that the event may have to be “halted momentarily.”
Mr Edwards, who worked as a mechanical engineer and is believed to have been a first time drug user, arrived at St James’s Hospital by ambulance just after 1.30pm on May 14.
He suffered a heart attack in the accident and emergency department, had a string of problems including internal bleeding and multiple organ failure and died just after 9am on May 15.
Dr Simon Flood, a consultant in critical care at Leeds Teaching Hospitals NHS Trust, told the inquest he did not believe Mr Edwards would have survived if he had been brought to hospital 20 or 30 minutes earlier.
Dr Flood said: “I think it is more likely the outcome would have been the same.”
Mr Edwards' mother Candace Edwards has met with Yorkshire Ambulance Service serious investigations team and representatives from Leeds City Council.
Mrs Edwards, said: "I have worked tirelessly since his death in the hope that changes will be made to ensure people's safety at events. I have met with many people, who have been empathetic, open and honest, to discuss areas that can be improved and I am hopeful for the future."
A spokesperson for Yorkshire Ambulance Service NHS Trust said: “First and foremost, our thoughts are with Josh’s parents and family following his tragic death in May last year.
“The trust has actively contributed to this inquest and welcomes the recommendations highlighted in the coroner’s report.
“We will continue to work with partner agencies to support the implementation of these recommendations.”
A Leeds City Council spokesperson said: “We work closely with our partners in the emergency services when planning events in the city and access for emergency vehicles is already a clear priority in this preparatory work.
"The importance of communicating details and procedures to all front line staff for future events will be emphasised at the significant pre-event planning meetings; we will also reiterate that access is prioritised for them when required.
"Public safety at events always takes precedence for us and we will look closely at what can be learned from the Coroner’s recommendations."
Recording a verdict of drug-related death, Mr McLoughlin said Mr Edwards’ death was a “monumental tragedy” for his family.