“Although this matter did not contribute to this death a concern was raised that a…”
Dated 25 Apr 2019, from the coroner for North East Kent. Sent to 3 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
Deadline passedReplies were due by 20 Jun 2019. A reply may have been sent and not yet published.
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.
- Report dated25 Apr 2019
- Deadline20 Jun 2019
- Published on judiciary.uk14 Jun 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South East Coast Ambulance Service NHS Foundation TrustNamed in the report as “South East Coast Ambulance Service” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jun 2019. A reply may have been sent and not yet published. |
| East Kent Hospitals University NHS Foundation TrustNamed in the report as “East Kent University Hospitals” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jun 2019. A reply may have been sent and not yet published. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 20 Jun 2019. A reply may have been sent and not yet published. |
The coroner’s concerns
– Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia there was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed. (1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained. (2) A consultant surgeon gave evidence that: a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital (3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
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, 2019-0127
- Added to Minute Book
- 8 Oct 2026
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- 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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