“The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had…”
Dated 14 Dec 2020, from the coroner for Black Country. 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 8 Feb 2021.
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 dated14 Dec 2020
- Deadline8 Feb 2021
- Published on judiciary.uk6 Jan 2021
- Today27 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 January 2021. |
The coroner’s concerns
– (1) The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest; (2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer; (3) There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased; (4) There was no note left by the attending paramedic crew detailing the outcome of the consultation; (5) the discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission; (6) The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR).
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, 2020-0281
- 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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