“(brief summary of matters of concern) (1) That a Critical Care Team was not dispatched…”

The coroner’s concerns

(brief summary of matters of concern) (1) That a Critical Care Team was not dispatched immediately given the serious nature of the call and the likely lack of clinical information for some considerable time ie waiting for the land ambulance, known to be more than 20 minutes away, to arrive and assess. (2) That the End Of Shift Policy was applied without evidence of an ongoing reassessment of the situation and the RRV, positioned only 3 minutes from the incident, was consequently not deployed. (3) There was clear evidence from the 999 call both from the caller and the obvious deterioration of Lucas from sounds in the background but that did not prompt a review of the management of the incident by EEAST. (4) While the medical evidence after consideration of the clinical presentation and the post mortem examination was clear that Lucas would not have survived, at the time of the call that was not and could not be known. Application of the policy as it was, in future situations, may represent a threat to a patient's life.

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, 2024-0058

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0