On 12 March 2025 I commenced an investigation into the death of Darryl JOHNSON aged
52. The investigation concluded at the end of the inquest on 09 March 2026. The Narrative Conclusion of the inquest was that: The Deceased died from an untreated pulmonary thrombo-embolism.

The Deceased had resided at 27b Market Square in Sandy since 2015. After failing to attend his work as expected on 24 February 2025, at around 21.55 hours that evening, his co-workers discovered him deceased at his home. Police attended and confirmed his death at 23.09 hours. Investigations revealed that at 06.17 hours earlier that morning, the Deceased had called ambulance services complaining of breathing problems and feeling faint. An ambulance crew was despatched just under an hour later. However, even though he had provided the correct address, the ambulance call handler, relying on the Ordnance Survey Map Database, had directed the crew to attend a different address, namely, 27a Market Square. When there was no response at that address, the crew called the Fire Service to force entry, but when no-one was found to be there the call response was closed. Had the crew been sent to the right address, the Deceased may have been found alive, although it remained unclear whether his death would have been avoided.