“The evidence from the attending paramedic was that she was not aware that symptoms of a…”
Dated 22 Jan 2025, from the coroner for Gateshead and South Tyneside. Sent to 3 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 19 Mar 2025. 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 dated22 Jan 2025
- Deadline19 Mar 2025
- Published on judiciary.uk23 Jan 2025
- 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 |
|---|---|
| North East Ambulance Service NHS Foundation TrustNamed in the report as “North East Ambulance Service” | Response publishedPublished on judiciary.uk in January 2025. |
| REDACTED | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| General Chiropractic Council | Response publishedPublished on judiciary.uk in January 2025. |
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
1. The evidence from the attending paramedic was that she was not aware that symptoms of a stroke can stop after a short time as clearly set out on NHS website and guidance, and that this was not part of her training. This was directly contrary to the Head of Operations’ evidence that this was part of both paramedic training and annual continuing professional development. This was a concerning feature given the accepted evidence of the time critical period to treat patients with symptoms potentially indicative of stroke. 2. The evidence on behalf of the treating chiropractor was that he did not consider it necessary to request GP records or hospital records, before assessment or treatment despite being informed about the Deceased’s recent hospital attendance, investigation which was recommended, and her discharge against medical advice. Even in the updated consent form I have been provided with, which was designed by the British Chiropractic Association, there is no prompt or question designed for the chiropractor to ask to consider obtaining medical records before assessment or treatment, and when this may be appropriate, and the only reference to medical records is a consent to communicate as deemed necessary for the treatment, and for a report to be sent to the GP after treatment. I am concerned that consideration to obtaining medical records should always be given before assessment, particularly where recent medical treatment or investigations has been undertaken.
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, 2025-0040
- 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