“That there is no clear pathway for interpretation of ECG traces to a specialist doctor…”
Dated 5 Jun 2026, from the coroner for North London. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 14 Aug 2026, after the 56 days for replies had ended (31 Jul 2026). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated5 Jun 2026
- Deadline31 Jul 2026
- Published on judiciary.uk14 Aug 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS England | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 14 Aug 2026, after the 56 days for replies had ended (31 Jul 2026). These dates can’t tell us whether a reply was due before it went online. |
| London Ambulance Service NHS TrustNamed in the report as “London Ambulance Service” | Response publishedPublished on judiciary.uk in August 2026. |
The coroner’s concerns
That there is no clear pathway for interpretation of ECG traces to a specialist doctor, when attending paramedics decide, where an ECG trace taken at the scene show abnormal automated interpretations, not to convey a patient to hospital. That Intermittent symptoms of:- - Chest Pain - Breathlessness - Abnormal ECG with some ST elevation (using one or more leads) did not result in the patient being taken to the nearest emergency hospital. That where the ECG is abnormal, the patient was not advised should show the copy of the ECG to their GP (unless the patient is taken to hospital). That there is no guidance on photograph of the ECG uploaded to the record of attendance being clear and readable. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. NHS England 2. The family 3. London Ambulance 4. 5. I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE HM Senior Coroner Mr Andrew Walker
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, 2026-0303
- 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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