“It is apparent that a communication error confused the ingestion of with a spillage of ”
Dated 31 Jan 2020, from the coroner for Warwickshire. 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 27 Mar 2020.
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 dated31 Jan 2020
- Deadline27 Mar 2020
- Published on judiciary.uk8 Feb 2020
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| West Midlands Ambulance Service University NHS Foundation TrustNamed in the report as “West Midlands Ambulance Service” | Response publishedPublished on judiciary.uk in July 2022. |
The coroner’s concerns
– (1) It is apparent that a communication error confused the ingestion of with a spillage of . (2) toxicity is a recognised method of suicide and I heard evidence from a WMAS staff member that there is an effective antidote (methylene blue) but this was not available on the ambulance.
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, 2020-0019
- 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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