“The family was under the impression that Brian was attended upon by paramedics rather…”

The coroner’s concerns

1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade. 2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be revisited, especially where a patient presents with dementia and may not be able to provide a full or accurate history. 3) The inquest was told that it will ordinarily be a SWAST ambulance that attends the MIU and there is a process whereby an ACRF can be sent electronically with the relevant past medical history. On this occasion, an LML ambulance attended whose staff work from written Patient Clinical Records. There was a conflict in the evidence as to whether a PCR was provided to MIU staff. One had to be subsequently requested by CPFT to review what had happened on the day. It may be appropriate to review how information is shared between different organisations. 4) Brian was seen by a triage nurse who ordered a knee x-ray only. 5) The nurse clinician was asked to review the x-ray only. There did not appear to have been any check as to whether Brian needed to be conveyed to RCHT which may have been appropriate if the complaint of groin pain had been noted. 6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment. 7) The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints.

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, 2025-0501

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0