On 08 June 2021 commenced an investigation into the death of Colin Michael SWAIN The investigation concluded atthe end of the inquest on 04 March 2022. The conclusion of the inquest was that Mr Swain died from Hypoxic brain injury due to aspiration of the gastric contents following Icohol intoxication: I was not possible on che balance of probabilities to determine the poin: at which Mr Swain $ brain was starved of oxygen such that he would stop breathing and whether turning him from his side to his back for CPR commencement caused or contributed to his death.

On 22 May 2021 Colin Swain, who had of alcohol excess, but did not drink in the presence of his family, was found collapsed in front after going outside for cigarette ana drink; The toxicology results indicated leve 0-akcohol ssociated Wth coma During the emergency call to the ambulance service the ca handler Ias informed that he had been drunk; had fallen hitting his head and was unconscious_ His breathing was assessed by the call handler and found to be agonal: The advice was to commence CPR for which he needed to be on his back; He was at that time on his side with his head doivn. Mr Swain vomited 35 he Ivas -urned and advice was given I0 Clear his Mouth; Immediazey upon turning him to his back Mr Swain stopped breathing: Bystander CPR followed until the ambulance service attended and achieved ROSC to Fransfer hospital, On admission the CT scan indicated hypoxia and he was presumed F0 have consumed enough Icohol t0 produce an obtunded state of consciousness wiith alcohol as the precipitant cause of death: Ainwvay protected reflexes could fail in these circumstances and in the absence 0f medica help, laryngospasm could be lethal, The clinical evidence was that he had aspirated his stomach contents which would itself have caused hypoxia worsened by degree 0f laryngospasm closing the ainway completely. The anoxic insult which can occur Vithin minutes asted long enough to stop his heart. The paramedic atrending the scene gave evidence that in agonal breathing the only course available :0 bystander wasto commence CPR pending arrival of an ambulance_ For that to nappen patien Dad[2pe onthelbadk aged bisto7i8" garden him lad

In my opinion acrion should be taken t0 preven: future deaths and believe You (andlor your organisation) have the powver t0 take such action, YoUR RESPONSE You are under a duty tO respond to this report within 56 days ofthe date of this report; namely by 05, 2022. [ the coroner, may extend the perod 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: