“Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and…”
Dated 15 Mar 2024, from the coroner for Avon. 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 10 May 2024.
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 dated15 Mar 2024
- Deadline10 May 2024
- Published on judiciary.uk20 Mar 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Western Ambulance Service NHS Foundation TrustNamed in the report as “South Western Ambulance Service Trust” | Response publishedPublished on judiciary.uk in March 2024. |
The coroner’s concerns
– (1) Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours; (2) His family raised their concerns regarding this with SWAS clinical stff on a number of occasions thoughout this period; (3) Staff repeatedly ascribed the respiratory effort to “a release of air”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment; The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL (4) There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment. The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL
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, 2024-0147
- Added to Minute Book
- 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
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