“(brief summary of matters of concern) (1) As a result of the collision Mr Dunn landed in…”
Dated 4 Jul 2024, from the coroner for Northamptonshire. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 29 Aug 2024. A reply may have been sent and not yet published.
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.
- Report dated4 Jul 2024
- Deadline29 Aug 2024
- Published on judiciary.uk7 Aug 2024
- Today23 Oct 2026
Watch this report
We’ll email you when a response is published on judiciary.uk, or when the 56 days to reply end with none published there yet. Free, and you can stop with one click.
Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in August 2024. |
| Medicines and Healthcare products Regulatory AgencyNamed in the report as “The Medicines and Healthcare products Regulatory Agency” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 29 Aug 2024. A reply may have been sent and not yet published. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
(brief summary of matters of concern) (1) As a result of the collision Mr Dunn landed in a prone position (on his front). In order for him to be treated by the pre hospital team he had to be moved out of this position to give ready access to his injuries. This necessitated the administration of analgesia. However, due to his positioning and the location of his injuries in conjunction with the extent of blood loss intravenous analgesics could not be administered. (2) Due to the experience level and qualifications of the pre hospital team in attendance, which included a Consultant Anaesthetist, an alternative form of analgesia, namely nasal morphine could be administered. (3) However, evidence was heard at the inquest that had the first attending team been a paramedic team they could not have administered this potentially lifesaving treatment as analgesia’s which can be delivered either nasally or buccally (via the cheek) are not presently available to paramedics despite being available to UK military personnel and mountain rescue teams. (4) I am concerned that the unavailability of such analgesics to paramedics to assist them to deliver potentially life saving pre hospital treatments or to enable a faster extraction of a patient where time is of the essence for medical treatment reflects a risk of deaths into the future.
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, 2024-0413
- 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
Ask about this report
AISummaries and questions, with page references. Pro and above.
Sign in to use