Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0526, written 10 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Oct 2025 |
|---|---|
| Reference | 2025-0526 |
| Deceased | William Puplett |
| Coroner | Andrew Walker |
| Coroner area | London (North) |
| Category | Emergency services related deaths (2019 onwards) |
| Organisation named | London Ambulance Service NHS Trust |
| 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 FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. International Academies of Emergency Dispatch. 1 CORONER I am Mr Andrew Walker, senior coroner for the coroner area of Northern London 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 the 11 November 2024 I commenced an investigation into the death of, William John Puplett, aged 78. The investigation concluded at the end of the inquest on 01 October 2025. The conclusion of the inquest was Consequences of a blocked tracheostomy tube at home where there was no working suctioning equipment. The medical cause of death was 1a Hypoxic Brain Injury, 1b Respiratory arrest from block tracheostomy tube, II Laryngeal cancer 4 CIRCUMSTANCES OF THE DEATH On the 9th November 2024 William John Puplett awoke in respiratory distress as his tracheostomy tube had become blocked and an ambulance was called at 5.06 hrs. The ambulance arrived at 6.45 to find that Mr Puplett had no pulse and had stopped breathing. Mr Puplett did not have a working suction unit at his home when he needed it on the 9th November 2024. Mr Puplett was taken to hospital where, having suffered a significant hypoxic injury, and despite treatment he died the same day. It is likely that had the ambulance arrived before 6.20 when Mr Puplett' s heart stopped, he may not have died when he did. 1 5 CORONER’S CONCERNS During the course of the inquest the evidence 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. – Consideration by the International Academies of Emergency Dispatch to add the following questions when dealing with a patient out of hospital or at home with a tracheostomy tube where there are difficulties with the tracheostomy tube and the patient is experiencing difficulty in breating. “Have you got suction equipment available and is there someone with the patient who is able to use the suction equipment ? And where the answer is no to either or both the result should be a Category 1 response . 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 Wednesday 03 December 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. 2. The family. – London Ambulance Service legal representative 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 other 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. 2 9 DATE: 10th October 2025 3
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.
International Academies of Emergency Dispatch
Request for Secondary Case Review
IAED Independent Case Review
6 January 2026
Bryon Schultz
Requested by: Mr. Andrew
Walker
Agency Contact:
London Ambulance Service NHS Trust
Quality Assurance Manager
Re: Independent Call Audit
Incident Reference:
IAED Reviewer(s):
Medical SME, Medical Council of
Standards
, IAED
CC:
Protocol Logic Version: 14.0.222
ProQA Program: 5.1.1.50
AQUA IPR: NA
Review Date(s): 12/18/ 2025
Incident Date(s): 11/09/2024
This case involves a 999 call requested to be independently reviewed by the IAED. The time
stamps reported here reflect the information obtained from the ProQA sequences report and do
not precisely align with the audio record. The total time recorded in the software records is
significantly less than the total audio record times. This may occur if information was obtained
before ProQA was opened and then entered rapidly without processing the previous
interrogation time.
Observations:
The audio recording for this case was 4 minutes and 33 seconds. The ProQA case sequence was 1
minutes and 16 seconds.
This 9-9-9 call was made by the patient's partner. Local Dispatch on Demand protocol was used
(awake and breathing?) and both questions were answered as Yes. The EMD then asked, “Ok, tell
me exactly what happened.” The caller stated her partner “…has a tracheostomy and is waiting to
go in for a laryngectomy and now has really trouble breathing tonight”. The line disconnected
after the address was asked. The EMD rang the caller back immediately and was reconnected
with the caller. The address and phone number were obtained and verified. The EMD continued
with Case Entry questions and determined the patient was awake and breathing. The EMD
correctly selected MPDS Protocol 6 (Breathing Problems). During Key Questioning, the caller
described the patient as responding normally (alert) and being in obvious distress. The caller's
response to the Key Question “Does he have any special equipment or instructions to treat this?”
was that they had a “nebulizer and that sort of thing.” The EMD informed the caller that the
response would be about an hour. The caller was provided with the instruction to call back if the
patient's condition worsened. The ProQA sequence indicates the use of the Urgent Disconnect
© 2026 IAED CONFIDENTIAL
Origin: 19 Dec 2025
3
option to end the call. This likely explains why no additional Case exit instructions were provided.
Findings: This reviewer found this case to be compliant with the IAED performance standards. The
EMD correctly identified the patient as being in obvious respiratory distress. The final MPDS code
assignment of 6-D-5 (Breathing Problems/Tracheostomy (obvious distress) was correct and
appropriate.
The caller was asked about having any special equipment to treat the complaint of tracheostomy
blockage.
The caller's answer did not include the availability of any special equipment, and it was
reasonably assumed, by the answer provided, that such equipment was not available.
Remarks:
Judging from the audio record, this reviewer has determined the EMD was compliant to protocol.
The resulting dispatch code, 6-D-5, was correct and appropriate for this call. The general resource
assignment recommendation for this DELTA level code is an immediate, ALS-level, Hot (lights and
sirens) response. However, actual response assignments are locally determined.
It should also be noted that staying on the line when dealing with an unstable patient in obvious
distress is highly recommended by the IAED, as is an immediate response assignment. However,
the situation in the communications center at the time this call was taken is unknown to this
reviewer.
Finally, it’s clear that a delayed response to this very ill patient was likely a factor in the poor
outcome of this case, despite the correct response code being generated.
Subject Matter Expert-Medical, IAED Medical Council of Standards
© 2026 IAED CONFIDENTIAL
Origin: 19 Dec 2025
4
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