“I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry…”
Dated 17 Jun 2024, from the coroner for Swansea Neath and Port Talbot. 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 12 Aug 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 dated17 Jun 2024
- Deadline12 Aug 2024
- Published on judiciary.uk25 Jun 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Welsh Ambulance Services University NHS TrustNamed in the report as “Welsh Ambulance Service NHS Trust” | Response publishedPublished on judiciary.uk in June 2024. |
The coroner’s concerns
– (1) I was told that paramedics and ambulance crew do not carry flumazenil (but often do carry naloxone). The availability of flumazenil was happenstance in this case because STEFAN was on an acute psychiatric ward where the said antagonist was being kept and could be prescribed by the ward pharmacist and administered by the doctors (with the support paramedics when they arrived). (2) I am concerned that there may be other acute circumstances when the use of this particular antagonist (flumazenil) could make a difference (say in the case of the collapse of person on the street or otherwise in the community) but will not be available since paramedics do not it. (3) I and the jury heard no evidence as to why naloxone is carried, but other antagonists (such as flumazenil) not.
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, 2024-0319
- 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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