Ian Bean
PFD Report
Historic (No Identified Response)
Ref: 2019-0340
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
5 Jan 2020
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns AI summary
An ambulance was incorrectly dispatched to the wrong address, sending it to Mr. Bean's father in a different county instead of to Mr. Bean.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action: am aware that your organisation has already reviewed the circumstances in which this error occurred: would be pleased to learn the steps you have taken to prevent this of error from happening again: Could you also please confirm whether those steps have been audited and found to be sufficient?
Report Sections
Investigation and Inquest
On 26 April 2018, an investigation was opened into the death of lan Thomas Trevor Bean who died on 14/4/18 at Liskeard in Cornwall: The matter concluded with an inquest held on 9/10/19. Mr Bean was found to have died from: 1A) multidrug toxicity
2) chronic obstructive pulmonary disease _ The conclusion recorded was that Mr Bean died by suicide_
2) chronic obstructive pulmonary disease _ The conclusion recorded was that Mr Bean died by suicide_
Circumstances of the Death
Mr Bean had become agitated and distressed at his home address on the date of his death: He had telephoned his father who lived in Nottingham and to whom he had not spoken for two years. He told his father that he had failed him as parent and that he was dying from an overdose of morphine (Oramorph) he had taken which was prescribed to him His father rang East Midlands Ambulance Service to request an ambulance for his son in Cornwall. In error; the ambulance was directed to his father's address in Nottingham. It was accepted at inquest that this error was not causative of the death as paramedics and police were also called to the address in Cornwall: Nevertheless, it was felt that this was an error of such a fundamental nature that action should be taken to ensure deaths did not occur in the future from a similar oversight: Way,
Information Classification: CONFIDENTIAL
Information Classification: CONFIDENTIAL
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.