Wayne Austin

3 June 2026 

Association of Ambulance Chief Executives 
25 Farringdon Street 
London 
EC4A 4AB 

Heath Westerman 
HM Assistant Coroner for the coroner area of 
Shropshire, Telford & Wrekin 

Dear Mr Westerman 

WAYNE AUSTIN (DECEASED) 

I am writing in response to the preventing future deaths report in my capacity as managing director of 
the Association of Ambulance Chief Executives (AACE). 

On behalf of AACE, I would like to extend our sincere condolences to the family of Mr Austin. 

AACE is a private company owned by the English and Welsh Ambulance NHS trusts. It exists to 
provide ambulance services with a central organisation that supports, co-ordinates and assists with 
the implementation of nationally agreed policy. Our primary focus is the ongoing development of UK 
NHS ambulance services and the improvement of patient care. It is a company owned by NHS 
organisations and possess the intellectual property rights of the Joint Royal Colleges Ambulance 
Liaison Committee (JRCALC) UK ambulance service clinical practice guidelines (the “JRCALC 
guidelines”). AACE is not constituted to mandate or instruct ambulance services, however, it has 
national influence via the regular meetings of ambulance chief executives and chairs along with a 
network of national specialist groups. We must emphasise that as a membership organisation, AACE 
is not responsible for the training or education of ambulance staff. 

Please note that we have liaised with the West Midlands ambulance service as they were also issued 
with the preventing future death report.  

We respond in relation to your matters of concern: 

1)  Difficulties in locating the appropriate tab for cardiac arrest (where opioid toxicity is the likely 

cause) on the JRCALC app for Naloxone meant it was missed and not applied. 

We are currently working on standardising all drug monographs through our Medicines Governance 
Group to ensure that all medicines monographs within JRCALC meet legal, regulatory, and good 
practice requirements. The naloxone monograph is currently under review, and we have shared the 
matters of concern with the lead person for the drug monograph and the JRCALC committee who 
have approved changes in response to your concerns.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2)  Inability of attending paramedics to comply with the guidelines for respiratory 

arrest/depression due to other competing tasks and therefore certainly a complete inability to 
comply with the guidelines for cardiac arrest (where opioid toxicity is the likely cause) making 
them potentially unrealistic. 

The JRCALC committee has approved the removal of the use of naloxone during cardiac arrest. The 
evidence that naloxone improves survival once cardiac arrest has occurred is limited. Furthermore, it 
may distract the attending clinicians from more important tasks such as early defibrillation, high quality 
chest compressions and effective ventilation. The use of naloxone will remain indicated for the 
reversal of acute opioid or opiate toxicity for respiratory arrest or respiratory depression; this is 
detailed in several of our clinical guidelines. We have also contacted the UK National Poisons 
Information Service to discuss the recommended cardiac arrest management for opioid poisoning.  

3)  WMAS ambulances only carry a box of 10 Naloxone 400mg vials per ambulance which 

means that one ambulance attending a situation such as Wayne’s would be insufficient to 
deal with the circumstances, as would two ambulances. It would mean that three 
ambulances are required to comply with cardiac arrest (where opioid toxicity is the likely 
cause).  

Following the recommendation by JRCALC committee to remove the use of naloxone during cardiac 
arrest, the amount of naloxone currently recommended would no longer be required.  

The changes agreed to the use of naloxone by the JRCALC committee will be reviewed by the  
national ambulance service medical directors group (NASMeD) and, subject to approval, will 
subsequently be introduced into ambulance service clinical practice guidelines.   

I hope this is helpful.  Please do not hesitate to contact me should you require any further information. 

Yours sincerely 

Managing Director

Mr Westerman 
Assistant Coroner for Shropshire, Telford & Wrekin 
Guildhall 
Frankwell Quay 
Shropshire  
SY3 8HQ 

13 May 2026 

Dear Mr Westerman 

Re: Wayne Austin  

Thank you for your email dated 10 April 2026 attaching your Regulation 28 Report.  

On behalf of West Midlands Ambulance Service (WMAS), I am sorry that you have had to 
raise concerns following the inquest of Mr Austin.  May I please take this opportunity to 
pass on my sincere condolences to the family of Mr Austin. I am deeply saddened by this 
case. 

Please see our response to your concerns. 

On  review  of  the  PFD,  including  Concern  3,  it  has  been  noted  that  there  are  some 
instances where drug dose units appear to be expressed using the abbreviation “mg”. In 
clinical practice, this denotes milligrams, whereas Naloxone Hydrochloride doses in this 
context are administered in micrograms. 

To  promote  clarity  and  avoid  any  potential  misunderstanding,  the  response  therefore 
refers to the dose of Naloxone Hydrochloride using the written term “micrograms” rather 
than abbreviations. 

Additionally,  Section  4  of  the  PFD  refers  to  a  “maximum  of  20,000  mg”  of  Naloxone 
Hydrochloride. This does not align with current JRCALC guidance. National guidance for 
Naloxone Hydrochloride in cardiac arrest describes a maximum cumulative dose of 10,000 
micrograms.  The  reference  within  the  PFD  therefore  appears  to  represent  an  incorrect 
expression of both the unit and the dose. 

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 Concern 1 

Difficulties  in  locating  the  appropriate tab  for cardiac  arrest (where  opioid  toxicity  is the 
likely cause) on the JRCALC app for Naloxone meant it was missed and not applied 

Response  

The  Naloxone  Hydrochloride  guidance  within  the  JRCALC  PLUS  App  is  authored  by 
JRCALC and digitally formatted and published by Class Publishing. WMAS do not have 
the ability to customise the format, layout, or navigation structure of the JRCALC PLUS 
App.  This  includes  the  location  of  drugs,  the  tabs  used  to  access  them,  and  the 
presentation  of  reference  tables.  These  design and  structural  elements are  determined 
centrally  by  JRCALC  and  Class  Publishing  and  are  applied  consistently  across  all 
subscribing ambulance services. 

Within the application, Naloxone Hydrochloride is accessed via the “Meds” tab and then 
by  selecting  the  “Naloxone  Hydrochloride”  monograph.  Within  this  section,  the 
administration guidance is available, including five quick reference dosage tables. One of 
these  tables  specifically  relates  to  Cardiac  Arrest  and  provides  dosing  guidance  for 
situations where opioid toxicity is suspected to be the underlying cause of the arrest. 

The  difficulty  described  therefore  reflects  a  usability  and  navigation  challenge  within  a 
nationally  provided  clinical  application.  The  relevant  clinical  information  was  available 
within the app at the time of the incident but was not accessed due to difficulty locating the 
appropriate section in a time-critical, high-pressure cardiac arrest resuscitation. 

WMAS is aware that Class Publishing is developing an “emergency mode” feature within 
the  JRCALC  PLUS  App.  This  functionality  is  intended  to  present  only  key  and  critical 
information to clinicians during true life-threatening emergencies and may help mitigate 
similar usability challenges in the future.  

We believe that resolving this concern sits with JRCALC / Class Publishing as they are 
responsible for the format of the guidelines and the JRCLALC Plus App.   

Concern 2  

Inability  of  attending  paramedics  to  comply  with  the  guidelines  for  Respiratory 
arrest/depression due to other competing tasks and therefore certainly a complete inability 
to comply with the guidelines for cardiac arrest (where opioid toxicity is the likely cause) 
making them potentially unrealistic. 

Response 

The Naloxone Hydrochloride administration guideline within JRCALC for cardiac arrest, 
where opioid toxicity is considered the likely underlying cause, recommends an initial dose 
of 400 micrograms administered intravenously or intraosseously, followed by second and 
subsequent  doses  of  800  micrograms  every  minute  to  a  maximum  cumulative  dose  of 
10,000  micrograms.  This  equates  to  the  preparation  and  administration  of  up  to  25 
individual  400  microgram  ampoules  of  the  currently  available  Naloxone  Hydrochloride 
presentation. 

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 WMAS recognises that, in the context of an active cardiac arrest, achieving this dosing 
regimen  is  not  realistically  achievable.  Cardiac  arrest  management  requires  the 
simultaneous  delivery  of  multiple  time-critical  interventions,  including  high-quality  CPR, 
airway  management,  ventilation,  rhythm  recognition,  defibrillation  where  appropriate, 
vascular  access,  drug  preparation  and  administration,  and  team  leadership.  Unless 
multiple additional clinicians are present with a designated role focused exclusively on the 
repeated  preparation,  checking,  and  administration  of  Naloxone  Hydrochloride, 
compliance with this aspect of the guideline is not practicable during resuscitation. 

As a result, while the guideline exists, full adherence in real-world cardiac arrest conditions 
is  constrained  by  human  factors,  task  saturation,  and  competing  clinical  priorities.  This 
does not reflect a lack of knowledge or intention to follow guidance, but rather the realities 
of delivering resuscitation care to a critically unwell patient in cardiac arrest. 

In  addition,  WMAS  notes  ongoing  clinical  uncertainty  regarding  the  pharmacological 
effectiveness  of  Naloxone  Hydrochloride  once  cardiac  arrest  has  occurred.  There  is 
limited  evidence  in  the  literature  demonstrating  benefit  from  Naloxone  Hydrochloride 
administration  in  established  opioid-induced  cardiac  arrest,  particularly  once  circulation 
has  ceased.  This  further  contributes  to  the  challenge  of  prioritising  repeated  Naloxone 
Hydrochloride  dosing  alongside  universally  accepted  resuscitation  interventions.  The 
WMAS  Medical  Director,  in  October  2025,  provided  an  update  at  the  WMAS  Learning 
Review  Group  meeting,  insofar  as  JRCALC  were  completing  a  further  review  of  the 
Naloxone Hydrochloride guidance. 

It  is  also  acknowledged  that  whilst  the  JRCALC  guidelines  state  that  Naloxone 
Hydrochloride  may  be  considered  where  opioid  toxicity  is  strongly  suspected,  its 
administration  should  not  delay  other  critical  interventions.  This  caveat  is  particularly 
relevant  in  cardiac  arrest,  where  the  immediate  focus  must  remain  on  high-quality 
resuscitation and restoration of circulation. 

Overall, this issue reflects a disconnect between guideline intent and what is operationally 
achievable  during  cardiac  arrest  resuscitation,  rather  than  an  unreasonable  failure  to 
follow  guidance.  WMAS  considers  that,  in  this  context,  the  guideline  may  not  be  fully 
realistic 
interpreted  pragmatically,  with 
patient-centred prioritisation of core life-saving interventions. The WMAS Medical Director 
has  raised  these  points  with  JRCALC,  and  it  is  our  understanding  that  the  Naloxone 
Hydrochloride guidance will be reviewed. 

frontline  application  and  should  be 

for 

We believe that resolving this concern sits with JRCALC / Class Publishing as they are 
responsible for the guidelines. 

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 Concern 3

WMAS ambulances only carry a box of 10 Naloxone 400mg vials per ambulance which 
means that one ambulance attending a situation such as Wayne’s would be insufficient to 
deal  with  the  circumstances,  as  would  two  ambulances.  It  would  mean  that  three 
ambulances are required to comply with cardiac arrest (where opioid toxicity is the likely 
cause). 

Response 

WMAS acknowledges that, based on the JRCALC cardiac arrest guidance, where opioid 
toxicity  is  considered  the  likely  cause,  the  cumulative  Naloxone  Hydrochloride  dose 
required would exceed the stock carried on a single ambulance, and a second ambulance. 
However,  WMAS  does  not  consider  this  to  represent  a  realistic  or  operationally 
appropriate benchmark against which the WMAS Drug Load List should be assessed. 

In established cardiac arrest, the efficacy of Naloxone Hydrochloride is inherently limited. 
Naloxone Hydrochloride exerts its effect through central antagonism of opioid receptors, 
primarily  within  the  brainstem.  In  cardiac  arrest,  systemic  circulation  ceases,  and  drug 
distribution to central receptors is therefore severely impaired. Even with high-quality chest 
compressions, cerebral perfusion remains markedly reduced, limiting the likelihood that 
Naloxone Hydrochloride administered intravenously or intraosseously will reach its target 
receptors in meaningful concentrations. 

As  a  result,  the  expected  clinical  benefit  of  Naloxone  Hydrochloride  dosing  in  cardiac 
arrest  is  low,  and  this  has  been  reflected  in  the  limited  evidence  base  demonstrating 
benefit  in  opioid-induced  cardiac  arrest  once  circulation  has  ceased.  This  significantly 
weakens the rationale for carrying large quantities of Naloxone Hydrochloride specifically 
to meet theoretical maximum doses outlined in JRCALC guidance. 

There  are  also  practical considerations  related to medicine  supply  resilience.  Naloxone 
Hydrochloride  has  previously  been  subject  to  national  supply  constraints.  Increasing 
carriage to 25 ampoules per ambulance, alongside maintaining sufficient reserve stock to 
support  fleet-wide  replenishment,  would  present  a  significant  logistical  and  financial 
burden.  When  weighed  against  the  limited  and  uncertain  benefit  of  Naloxone 
Hydrochloride  in  cardiac  arrest,  this  does  not  represent  a  proportionate  risk-benefit  or 
cost-benefit intervention. 

WMAS has undertaken formal clinical review of this issue. An initial review of Naloxone 
Hydrochloride quantities was completed in May 2025 by the WMAS Consultant Paramedic 
for Emergency Care, followed by a further review in September 2025 by the senior clinical 
team.  The  latter  specifically  considering  the  cardiac  arrest  guidance  where  opioid 
overdose  is  suspected.  The  consensus  from  the  latest  review  was  that  the  current 
Naloxone Hydrochloride quantities carried on the WMAS Load List were appropriate. 

This assessment was informed by several mitigating factors, including the routine dispatch 
of  additional  resources  to  cardiac  arrest  calls,  the  limited  evidential  value  of  Naloxone 
Hydrochloride in established cardiac arrest, and the operational impracticality of delivering 
repeated high
dose Naloxone Hydrochloride during active resuscitation. Fundamentally, 
it was concluded that the JRCALC cardiac arrest Naloxone Hydrochloride guidance is not 
practically deliverable or clinically effective. The current WMAS Load List of 10 Naloxone 
Hydrochloride  ampoules  on  an  ambulance  is  aligned  to the management  of  respiratory 

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 arrest or respiratory depression guidance; where the maximum dose is 4,000 micrograms 
which is 10 administrations of 400 micrograms Naloxone Hydrochloride every 3 minutes. 

WMAS  believe  that  the  current  JRCALC  Naloxone  Hydrochloride  guideline  requires 
amendment,  either  due  to  the  practical  challenges  associated  with  compliance  in  the 
pre-hospital  cardiac  arrest  setting  and/or  a  lack  of  robust  pharmacological  evidence  to 
support its effectiveness as currently described. The WMAS Medical Director has raised 
these points with JRCALC, and it is our understanding that the Naloxone Hydrochloride 
guidance is currently being reviewed. Given this, our intention is to await clarification from 
JRCALC on these changes.  

I hope this response provides you with the appropriate level of assurance that as a Trust 
we have dealt with the concerns highlighted within your report and the extent to which we 
take patient safety very seriously.  

May I once again please pass on my sincere condolences to the family of Mr Austin.  

If you require any further assistance, please do not hesitate contact me. 

Your sincerely, 

Service Transformation & Patient Safety Director 

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