A man described as special by his father died after taking a controlled poison, linked to seven recent deaths in Greater Manchester.
William Armstrong was just 24 when he died after taking the substance which he had ordered online and had come from Russia.
An inquest into his death took place this week with the coroner stating he will be writing to the Department for Health to outline his concerns about the response of the ambulance service after it took nearly an hour-and-a-half for paramedics to reach Mr Armstrong, who had called for help.
Mr Armstrong was described as a “special man” who “loved philosophy and music.”
He took the substance in a hotel room on Chorley New Road in May last year.
Mr Armstrong called the ambulance to request help telling North West Ambulance Service what he had done - but paramedics took 89 minutes to respond.
Mr Armstrong was pronounced dead at the scene.
Bolton Coroners Court heard Mr Armstrong appeared to have bought the substance online from Russia and had left his home on Brooklands, Horwich, to book into the hotel room.
Peter Ballan, a senior manager at the North West Ambulance Service, told the court the call had been graded as category two, which meant paramedics had been diverted away from it to another call.
A category one call means the response time should be on average seven minutes and 15 minutes nine out of 10 times.
For a category two the average is 18 minutes and should be 40 minutes nine out of ten times.
The court heard there were category one calls were made at 9.51pm, 10.58pm and 11.14pm that night on what was a "busy evening."
Coroner Timothy Brennand said: “What is sore for the family is had the ambulance arrived within seven minutes, who knows what the outcome might have been?”
Mr Ballan said the categories were set by national guidelines.
Mr Brennand said: “I am going to write to the Department of Health to raise my concerns, there is a risk of future deaths if the poison is administered, then someone calls an ambulance, if it is raised as a category two response it gives rise to delays.”
He said there had been a “cluster” of seven deaths which he had overseen the inquests of which had been linked to the substance.
Matthew Price, from Breightmet, used the same substance to take his own life in June 2021.
Father John Armstrong said in a statement said: “He was a special man.
“He loved philosophy and music, he played guitar, music seemed to take him away.”
He said he had suffered with mental health difficulties from the age of 14 characterised by low mood and lacking energy.
Pathologist Julie Evans said she was aware of the poison type which Mr Armstrong had taken, and said she found it is now harder to obtain online than a few months ago.
Detective Inspector David Henshaw was sent to the hotel on the night of Mr Armstrong's death.
He said a bottle of the controlled poison was found at the scene.
He added: "There was an envelope on the desk which had been sent from Russia."
He also said GMP was "very familiar" with the substance.
The coroner said he could not be persuaded on the balance of probabilities that Mr Armstrong intended to take his own life as he had not left a note, had called the ambulance and had consumed alcohol at the time.
Mr Brennand returned a narrative conclusion, stating Mr Armstrong died following the self-ingestion of the controlled poison.
He said: "I do not feel accident or drug death or overdose is appropriate.
"The evidence established he had acquired it from Russia.
"It is clear to me he died as a dreadful consequence of ingestion of this.
"I am not satisfied on balance that he wanted to die.
"There was no evidence of a note.
"There is no suggestion he had put his affairs in order."
He said of the sending of a Section 28 regulation: "My personal view is that staff need to change the classification of response on an overdose from category two to one.
"This is just the view of one local coroner.
"It needs to be taken to higher levels."
Mr Brennand said there had been a police investigation into the sale of the product taking place elsehwhere in the country but this was "now at an end."
He asked for the product not to be named as he did not want it to be given the "oxygen of publicity."
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