“(brief summary of matters of concern) The attending paramedics did not take the…”
Dated 5 Jun 2025, from the coroner for Cheshire. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 31 Jul 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated5 Jun 2025
- Deadline31 Jul 2025
- Published on judiciary.uk17 Jun 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North West Ambulance Service NHS TrustNamed in the report as “North West Ambulance Service” | Response publishedPublished on judiciary.uk in June 2025. |
The coroner’s concerns
(brief summary of matters of concern) The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson's blood pressure. Regulation 28 – After Inquest Document Template Updated 30/07/2021
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0281
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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