Ivy Dixon

His Majesty's Coroner 

Inner North London Coroners Court 

Inquest touching the death of Ms Ivy May Dixon  

STATEMENT OF 

LAS Ref: 15641  

I will say as follows: 

Background 

1. 

My  name  is 

;  I  am  the  Senior  Clinical  Lead  for  Legal  Services  for  the  London 

Ambulance Service NHS Trust. I have responsibility of clinical oversight for cases involving legal 

services.  My  main  responsibilities 

include  reviewing 

inquests  and  clinical  claims, 

representation  of  the  Trust,  undertaking  incident  investigations  (including  patient  safety 

investigations), Learning from Death reviews via Structured Judgement Reviews and providing 

clinical  opinions.  I  remain  in  active  clinical  practice  and  regularly  undertake  shifts  as  a 

Paramedic and as Senior Clinical advisor for the Trust.    

2. 

My full qualifications are: Bachelor of Science Degree (Honours) in Paramedic Science. I have 

been a Paramedic registered with the Health and Care Professions Council (PA34712) since 

2012 and am a member of the College of Paramedics. Prior to undertaking this role, I was one 

of Trusts Quality, Governance and Assurance Managers responsible for North Central Sector 

as well as a Staff Officer to the Deputy Director of Operations 

Purpose of The Report and Materials Examined:  

1. 

Thank  you  for  requesting  this  clinical  statement  covering  a  clinical  review  of  the  incident 

involving Mrs Ivy May Dixon attended to by the London Ambulance Service (LAS) on the 06 

October 2024. This statement will provide an overview of clinical care provided to Mrs Dixon, 

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LAS Ref: 15641 

 
 
 
 
 
 
 
 
 
 
 and will seek to address the following concern raised by HM Coroner: 

2. 

3. 

“Assistant Coroner Potter heard evidence from a registered nurse at Acorn Lodge Care Home 

(the  current  Home  Manager)  that  because  choking  is  regarded  as  a  reversible  cause,  they 

consider that CPR should have been provided to Mrs Dixon on 6 October 2024.” 

I have had no direct involvement with the care or treatment of Ms Ivy May Dixon. 

I have reviewed the following documents as part of my review:  

  Electronic call log for CAD 3998 on the 06 October 2024.   

  Audio tape for CAD 3998 on the 06 October 2024.   

  Electronic  Patient  Care  Record  (ePCR),  case  reference  number  M1XV16390D6E 

completed on the 06 October 2024 by the attending clinician.  

  Signed statement of Paramedic 

, dated 07 January 2025. 

  Signed addendum statement of Paramedic 

, dated 13 February 2025. 

  Post Mortem Report dated 07 January 2025, consultant pathologist 

.  

Timeline of London Ambulance Service Involvement on Scene 

For noting: The times provided can be sourced from different references, the times detailed from the 

control room records are derived from the control room computer system and this is synchronised with 

an electronic clock for accuracy and recorded on the call log. The defibrillator has an electronic clock, 

which is checked on service, and when connected to a computer but can show a slight difference to the 

times on the control room system. In terms of the times an ambulance clinician records on the clinical 

record this may be from a personal watch or potentially an estimate of the time. Clinical Record timings 

are often completed following patient handover and require manual manipulation of the automatic 

clock. This can often lead to discrepancies in relation to the timings on the clinical record. 

Time 

Time  
Elapsed 

Detail 

18:15 
(hours: 
minutes) 

00:00 
(hours: 
minutes) 

A 999 call (CAD 3998) was received and answered immediately. The patient was 
reported to be breathing and conscious. The call was for a 96-year-old female with 
the problem description provided as “Choking”.  

06 October 2024  

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LAS Ref: 15641 

 
 
 
 
 
 
 
 18:18  

00:03 

18:21 

00:06  

18:29 

00:14 

The call was triaged by Medical Priority Dispatch System (MPDS)1 and received the 
determinant “(11D1F) - Abnormal breathing (PARTIAL obstruction)”. This received 
a pre-determined category 1 response profile2. 
A Fast Response Unit (FRU), call sign G350, staffed by a Paramedic was dispatched 
to the incident location.  

A Double Crewed Ambulance (DCA), call sign K335, staffed by a Newly Qualified 
Paramedic (NQP) and a Trainee Assistant Ambulance Practitioner (TAAP) was 
dispatched to the incident location.  
FRU, call sign G350, arrived on scene at the incident location. Following arrival the 
clinician was met by care home staff and led to a bedroom where Mrs Dixon was 
located in a hospital bed.  

An initial assessment was undertaken, which identified that Ms Dixon was 
unconscious, not breathing and had no palpable pulse indicating she was critically 
unwell and in confirmed cardiac arrest.  

The following history was provided: It was recorded, “Care home staff were 
attempting to feed the pt [patient] this evening, noted the pt was only eating 
liquids and was not for solid food. As staff were attempting to feed pt state [sic] 
that she became unresponsive and made “gasping” sounds therefore were unable 
to give her any food. Staff were concerned so called 999. As staff were unable to 
actually feed pt no liquids were given to pt – not a reversible cause. No evidence of 
vomit or liquids in the airway”.  
G350 contacted the Emergency Operations Centre (EOC) and advised that Ms 
Dixon was in cardiac arrest and that no further resources were required. K335 was 
stood down from the incident.  

The following note was recorded on the log: 
‘Pat [patient] deceased, DNJAR [sic – DNACPR] in place, NFRR [no further resources 
required]’ 
A set of observations was recorded as follows: 

18:31 

00:16 

• 
• 
• 

• 

Respiratory Rate – 0 breaths per minute 
Heart Rate – 0 beats per minute 
Pupils – 7mm, both fixed (indicating that Mrs Dixons pupils were dilated 
and not reactive to light) 
Glasgow Coma Scale – 3/15 (indicating Mrs Dixon was unconscious) 

A cardiac rhythm analysis was undertaken which identified that Ms Dixon was 
asystolic3   

1 Medical Priority Dispatch System is a national call taking system which assists call handlers to triage calls and 
establish a response profile.  
2 Category 1 calls as a cohort of calls have a mean response target of 7 minutes and a 90th centile response 
time target of 15 minutes. This is a commissioning target for the total number of calls of a specific category 
and is not assigned to an individual call. Even where an ambulance service is achieving its 90th centile target, 
there will still be response times for individual calls which fall outside of the target.  
3 Asystole represents total cessation of electrical and mechanical activity of the heart.  

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LAS Ref: 15641 

 
 
 
 
 
 
 
 
 
                                                           
 Verification of the fact of death was completed citing a DNCPR was in place and 
confirmed the patient had no pulse or respirations. All required examinations were 
completed. 

Call Handling and Dispatch 

4. 

5. 

6. 

It is outside the scope of this review to comment on the handling and accuracy of the 999 call 

but I note the call was triaged as category 1 which is the highest response profile. With the 

current information available this appears appropriate.  

It is noted that the overall response time to the call was 6 minutes.  

On  review  an  appropriate  number  and  skill  of  resources  were  dispatched  to  the  call.  The 

double crewed ambulance was cancelled by the attending clinician following their arrival.   

Summary of Clinical Care 

7. 

I  note  that  Ms  Dixon  was  at  the  time  of  her  death  a  96  year-old-female  with  a  history  of 

dementia and hypertension (high blood pressure). The clinical record suggests that she was 

bed bound and was noted to be on a liquid diet suggesting she had reduced mobility and a 

level of frailty and likely a poor swallow.  

8. 

I note a provisional cause of death has been provided as:  

1a.   Asphyxia 

1b.   Choking on Food 

II.   Essential hypertension and Type II diabetes mellitus 

9. 

On review of the post mortem I note a key finding indicated that “the tracheo-bronchial tree 

was  obstructed  by  greenish/grey  pureed  food”.  To  assist  with  understanding,  Ms  Dixon’s 

breathing pipe (trachea) was obstructed with pureed food to the point at which the trachea 

divides into the left and right lung (bronchus). This is outlined in the diagram below.  

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LAS Ref: 15641 

 
 
 
 
 
 
 
 
 
 
 
 Management of Ms Dixon 

10. 

On arrival of the clinician, they were promptly shown to the location of Ms Dixon. She was 

noted to be semi-recumbent in a hospital bed and in receipt of oxygen via a high flow mask. 

No further treatment was being provided by the care home staff at the time of their arrival. 

There was no ongoing resuscitation.  

11. 

The clinician undertook a primary survey. This identified that Ms Dixon was unresponsive, was 

not breathing and had no detectable pulse (indicating there was no palpable heart beat). This 

indicated  that  Ms  Dixon  was  in  a  confirmed  cardiac  arrest.  The  clinician  confirmed  no 

bystander CPR had been provided prior to their arrival.  

12. 

The clinician ascertained that Ms Dixon had become unresponsive as staff at the home were 

attempting to feed her, she was noted to have made gasping noises and 999 was contacted. 

The staff informed the clinician that no food had been provided to Ms Dixon prior their arrival 

on  scene  and  further  that  Ms  Dixon  had  a  do  not  attempt  cardiopulmonary  resuscitation 

(DNACPR) order in place.  

13. 

The clinician appropriately undertook a visual inspection of Ms Dixons airway from her semi-

recumbent  position in  the hospital  bed. This would likely  have enabled visualisation to the 

back of the mouth (oropharynx). On inspection there was no noted food detritus to indicate 

that Ms Dixon’s cause of arrest was choking. In consideration of this along with the fact the 

staff  had  advised  they  had  not  provide  Ms  Dixon  with  any  food  in  conjunction  of  the 

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LAS Ref: 15641 

 
 
 
 
 
 
 knowledge that Ms Dixon has a DNACPR in place, the clinician made the decision that Ms Dixon 

was unlikely to be choking and as a result, undertook verification of the fact of death at 18:31 

considering the cause of the arrest was likely in line with the DNCPR. No further treatment 

was provided.  

14. 

Clinical guidelines in relation to presentations of choking when a valid DNACPR is in place are 

presented within JRCALC (Joint Royal College Ambulance Liaison Committee) guidelines under 

‘Termination of Resuscitation and Verification of Death in Adults’. This is included below: 

JRCALC, (2022), ‘Termination of Resuscitation and Verification of Death in Adults’ 

15. 

Choking  is  considered  a  reversible  cause,  and  therefore  consideration  should  be  made  to 

clinical treatment. Where a clinician is presented with an unconscious patient as a result of 

choking,  expectations  are  that  LAS  clinicians  consider  national  JRCALC  guidance  which  is 

provided below:  

16. 

In this case, the clinician appropriately undertook a visual inspection of the airway, however, 

one could considered a further examination with a  laryngoscope4. Had this occurred it would 

4 A laryngoscope is an instrument consisting of a blade and handle which is inserted into the patients mouth to 
enable visualisation of the of the larynx and vocal cords. It allows further review of a patient’s airway.   

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LAS Ref: 15641 

 
 
 
 
 
 
 
                                                           
 have enabled further visualisation of the patient’s upper airway to the opening of the larynx 

(up to the vocal cords). A diagram is provided below to assist with visualisation of this.  

17.  Whilst this is considered, it is important to note that the use of suction prior to the arrival of 

the clinician may have removed any blockage or evidence of detritus above the larynx.  Further 

given  the  description  of  the  blockage,  it  would  not  have  been  possible  to  visualise      any 

blockage below the vocal cords. In consideration of this there would have been no blockage 

which the clinician could either have identified or removed.  

18.  Where  a  patient  has  aspirated  (where  food,  liquid  or  foreign  substances)  are  accidently 

inhaled into the trachea and lungs (beyond the vocal cords), there is limited treatment options 

available to the clinicians and where this has occurred, there is limited success in removal.   

19. 

Once the airway has been examined and any obstruction removed, guidance advises that basic 

life support should be initiated. One is minded to consider that on arrival of the clinician Ms 

Dixon  was  in  confirmed  cardiac  arrest.  On  review  of  the  statements  and  clinical  record 

provided, there had been no provision of cardio pulmonary resuscitation prior to the arrival 

of the clinician and the time at which she deteriorated into cardiac arrest was unknown.  

20. 

On review of the information provided, and in consideration of Ms Dixon’s previous medical 

history and evident frailty, once must consider that whilst basic life support could have been 

initiated it would be very unlikely to have resulted in a successful outcome. There is a careful 

balance between ensuring a patient receives medical care and that any care provided will have 

a meaningful outcome.    

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LAS Ref: 15641 

 
 
 
 
 
 
 
 21.  Where a patient has deteriorated into cardiac arrest as a result of choking, the prognosis of a 

patient is extremely poor. Current data is suggestive of a less than 6% survival rate When you 

consider this figure in the context of a patient with marked frailty and no immediate option to 

clear the airway any chance of survival would have been minimal at the most.  

22. 

 In consideration of the information provided on the 999 call, the caller advised that Ms Dixon 

had started choking following being fed, that her oxygen saturations were deteriorating, they 

had used suction, she had shallow breathing and they had applied oxygen. On review, It is not 

clear  why  the  information  provided  to  the  999  call  handler  differed  to  the  information 

provided  to  the  clinician  on  scene.  Had  the  clinician  been  informed  of  the  circumstances 

outlined  on  the  999  call,  it  is  not  unreasonable  to  consider  that  the  clinician  would  have 

considered the cause of the arrest to be choking but on balance I am not of the view that with 

no  obvious  obstruction  of  the  airway  this  would  have  changed  either  any  intervention  or 

outcome.  

23. 

The  completed  clinical  record,  subsequent  clinical  statements  and  discussions  with  the 

clinician  indicate  that  at  the  time  of  the  attendance  to  Ms  Dixon  they  were  aware  of  the 

guidance. Whilst this is recognised, there were indications of an obstruction and whilst in my 

opinion their care was not wholly unreasonable, they have been receptive to feedback. Their 

verbalised insight and reflection of the attendance to Ms Dixon has been commendable.  

I would like to take this opportunity to extend my deepest sympathies to the family and friends of Mrs 

Dixon and would like to apologise for any distress caused by this statement. 

STATEMENT OF TRUTH   

I confirm that I have made clear which facts and matters referred to in this report are within my own 

knowledge  and which are not. Those  that  are within my own knowledge  I confirm to be true. The 

opinions I have expressed represent my true and complete professional opinions on the matters to 

which they refer.  

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LAS Ref: 15641 

 
 
 
 
 
 
 
 
 
 
 DECLARATION   

I, 

 declare that:   

I understand that my duty included in my providing written reports and giving evidence is to help the 

court  on  the  matters  within  my  expertise.  I  confirm  that  I  have  complied  with  that  duty  and  will 

continue to comply with it. This report is addressed to the court.  I understand that this duty overrides 

any obligation to London Ambulance Service NHS Trust.  

Name:  

Signature: 

Date: 24th February 2025 

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LAS Ref: 15641 

 
 
 
 
 
 
 
 
 Confidential 

IN THE PROPOSED MATTER OF AN INQUEST INTO THE DEATH OF 

Ivy May Dixon 

_______________________ 

WITNESS STATEMENT OF  

________________________ 

________________________________________________________________ 

I, 

 WILL SAY as follows: 

1.  I am a Band 6 paramedic and I have been working for the London Ambulance Service 
(LAS) since the 1st of July 2021. My station/base is Cody Road Ambulance Station.  

2.  I have been requested to complete a witness statement by the Coroner. It has been 

requested that I cover when I arrived on scene to when the deceased was left in the 

care of others.  

3.  I  have  referred  to  the  ePCR  to  prepare  this  statement.  No  other  documents  or 

references have been used.  

4.  On the 6th of October 2024 I was working under the call sign of G350 out of Homerton 

Ambulance Station. At 18:18 I was dispatched to CAD 3998, it was given as category 

1 call with the chief complaint of choking with abnormal breathing.  

5.  I arrived on scene at 18:21 and was met by care home staff outside. I was led inside 

and into the patients bedroom, the patient was in a hospital bed in a semi-recumbent 

position with high flow oxygen mask on the patients face.  

6.  In the room was two care home staff and a nurse.  

7.  When I assessed the patient they were not breathing and did not have a pulse. I asked 

the staff what had happened and they had stated that they were attempting to feed the 

patient thick liquids when she became unresponsive and made a gasping sound.  

 
 
 
 
 
 
  
 
 
 
 
 
 8.  I clarified with the staff that they were unable to feed the patient any food. No food was 

given to patient.  

9.  Staff stated that is when they called 999. 

10. Staff  on  scene  including  the  registered  nurse  stated  that  no  CPR  was  commenced 

prior to LAS arrival.  

11. The  nurse  who  was  present  stated  that  the  patient  had  a  DNAR  (do  not  attempt 

resuscitation), she presented the valid DNAR to myself.  

12. I  assessed the  patient’s airway  and no food,  liquid  or secretions  present, confirmed 

with staff that they were unable to feed patient as she was unconscious.  

13. To assess the patient’s airway I opened her mouth and visually inspected the airway 

which was clear and no evidence of food was found. 

14. There is  no  official  mention  of  the  processes/procedures for  airway  management  in 

patients who have suspected choking in the LAS Airway Management Policy OP077.  

15. In  our  JRCALC  (Joint  Royal  Colleges  Ambulance  Liaison  Committee)  guidelines  it 

advises  that  for  an  unconscious  patient  with  a  severe  airway  obstruction  you  begin 

CPR. To manage the airway you open the mouth and look for any obvious obstruction. 

Then attempt to visualise the vocal cords with a laryngoscope. If an obstruction is seen 

and it can be grasped easily, make an attempt to remove it with forceps, or suction.  

16. As the staff on scene specifically stated to myself that they were unable to feed the 

patient, there was a low clinical suspicion of choking so CPR was not commenced. 

17. With  LAS  guidance  if  the  cause  of  cardiac  arrest  was  choking  it  is  deemed  as  a 

reversible cause and BLS should be started even if the patient has a DNACPR.  

18. As the patient was not breathing, did not have a pulse and had a valid DNACPR no 

BLS (basic life support) was attempted.  

19. I  updated  EOC  (emergency  operational  centre)  stating  that  there  was  no  further 

resources required.  

20. I confirmed ROLE (recognition of life extinct) at 18:31.  

21. I then left the patient in the care of both the nurse and two further care home staff in 

the patient’s bedroom and completed my paperwork in my vehicle.  

Statement of Truth 

The contents of this statement are true to the best of my knowledge and belief. 

Signed:

………………………….…….. 

 
 
 
 
 
 Dated: ....13/02/2025..........................................................................