Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0281, written 5 Jun 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2025 |
|---|---|
| Reference | 2025-0281 |
| Deceased | Edward Wilson |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| Category | Emergency services related deaths (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 NWAS (North West Ambulance Service) 1 CORONER I am Jacqueline DEVONISH, Senior Coroner for the coroner area of Cheshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 03 January 2025 I commenced an investigation into the death of Edward Thomas WILSON aged 86. The investigation concluded at the end of the inquest on 04 June 2025. The conclusion of the inquest was that: Narrative Conclusion - Died following the administration of salbutamol nebulisers in the context of unrecognised significant heart failure 4 CIRCUMSTANCES OF THE DEATH Mr Wilson was attended at home by paramedics and on the second attendance transported to hospital by the ambulance service. The statements of the paramedics confirm that his observations were within normal ranges but that when auscultating his lung fields some fine crackles were heard from both lung bases without wheeze or stridor when attended at 11:43 hours on 28 December 2024. This was not on the face of it unreasonably diagnosed as a potential chest infection and was agreed by the GP AVS based at the hospital who dispensed antibiotics having taken into account the clinical history. When reattending at 19:35 hours Mr Wilson had a raised respiratory rate, a global wheeze on air, shortness of breath/difficulty breathing had worsened. The paramedics administered a salbutamol nebuliser as well as an ipratropium nebuliser which lasted the duration of the transit to hospital until cardiac arrest. The Consultant in Emergency Medicine stated that the withdrawal of blood pressure medication and administration of salbutamol nebulisers in the context of a known clinical history of significant heart failure contributed to the lowering of his blood pressure and repeated cardiac arrests on route to hospital. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson's blood pressure. Regulation 28 – After Inquest Document Template Updated 30/07/2021 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by July 31, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Legal Department, Macclesfield District General Hospital I have also sent it to Meadowside Medical Centre who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 05/06/2025 Jacqueline DEVONISH Senior Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Ms Jacqueline Devonish His Majesty’s Senior Coroner Cheshire Coroners Court By Email Only 24 July 2025 Dear Ms Devonish LADYBRIDGE HALL 399 Chorley New Road Bolton BL1 5DD T: 0345 112 0999 nwas.nhs.uk Regulation 28 Report – Inquest Touching the Death of Edward Thomas Wilson I write further to your Prevention of Future Deaths Report dated 5 June 2025, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Mr Wilson. I am aware that you will share my response with Mr Wilson’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter I will address those concerns as far as I am able. The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson’s blood pressure. Upon receipt of the Regulation 28 report a decision was made to undertake a retrospective Specialist Review into the treatment and care provided to Mr Wilson. NWAS was not aware of any concerns regarding Mr Wilson’s care prior to the conclusion of the inquest, and the witness statements provided did not highlight any failures in practice or procedure. NWAS was not present or represented at the inquest and did not have Interested Person status to the proceedings. The Specialist Review has been carried out by an NWAS Sector Clinical Lead, and a copy of the Review is attached to my letter for completeness. However, I have summarised the key findings below which I hope is of assistance. Headquarters: Chair: Chief Executive: Ladybridge Hall, 399 Chorley New Road, Bolton BL1 5DD Delivering the right care, at the right time, in the right place; every time. The assessment of Mr Wilson was conducted in a timely and structured way. Mr Wilson’s clinical presentation suggested a primary respiratory issue. Auscultation of Mr Wilson’s lungs revealed a “global wheeze” meaning that wheezing could be heard throughout his lungs. The treatment of wheeze and associated shortness of breath was commenced using oxygen driven nebulised salbutamol 2.5mg in 2.5ml at 19:40 hours. A further repeat dose of salbutamol was issued concurrently with Ipratropium Bromide at 20:12 hours. The Specialist Review indicates that treatment of Mr Wilson’s shortness of breath, in the context of pulmonary wheeze, should include the use of salbutamol driven by oxygen as outlined below: Salbutamol JRCALC (Joint Royal Colleges Ambulance Liaison Committee) provides a national framework of standards and treatment guidelines for the provision of pre hospital care as delivered by ambulance services. Paramedics, prior to issuing any medication, are advised to consult JRCALC to ensure the appropriateness of their treatment plan. The Specialist Review concludes that Salbutamol would have been indicated for Mr Wilson as he was suffering with expiratory wheeze associated with a lower airway cause, presumed to be infection. There was no absolute contraindication for using Salbutamol. The Review acknowledges that Mr Wilson had a recorded history of hypertension and therefore a long dosing interval should be used. A dose interval of 5 minutes is advocated by JRCALC, however in Mr Wilson’s case a dose interval of 32 minutes is recorded between both administrations of Salbutamol. The use of salbutamol in the treatment of Mr Wilson’s illness was indicated and substantiated as appropriate by the national guidelines. The Specialist Review has concluded that the treatment afforded to Mr Wilson adhered wholly to the national guidelines produced by JRCALC and I hope this addresses the concerns you have raised. There were no contraindications to the use of salbutamol despite Mr Wilson’s medical history. Therefore, any risk resulting from adherence to these guidelines is born at a national scale and should be directed to JRCALC directly. I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, . Yours sincerely Chief Executive
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