“1 There was a miscommunication, or misunderstanding, between the control room and the…”

The coroner’s concerns

5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back. 5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem. 5.3 It is clearly important that a continual assessment of the patient’s presenting symptoms are relayed to the ambulance crew and how best to deploy resources given the circumstances of any individual case. The evidence at the Inquest was that no such assessment was undertaken. I should make it clear that I found no evidence that an earlier attendance by the ambulance crew would have resulted in a different outcome for Mr Selman who sadly went into cardiac arrest just prior to arriving at the John Radcliffe Hospital and, despite the best efforts of the staff at the hospital, he could not be revived. I would also say that , on behalf of your service, provided me with a helpful report which assisted my inquiry and gave a very open and honest account of his assessment of the circumstances of this case. 6. Action should be taken 6.1 In my opinion action should be taken to prevent future deaths and I believe your service has the power to take such action. 6.2 Such action should include: (a) reviewing the communication arrangements between the control room and the ambulance staff to ensure that they fully understand the request to stand down as opposed to any request to stand back; NG / ADC / 097089 Page 3 (b) ensuring that staff continually assess the patient’s presenting symptoms to ensure the attendance of appropriate resourced ambulance crew. 7. Your Response 7.1 You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 November 2013. I, the Coroner may extend the period. 7.2

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, 2013-0354

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8 Oct 2026

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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