UK Inquiry Tracker

Winston Llewellyn Johns

PFD Report Historic (No Identified Response) Ref: 2013-0279

Date of Report 30 October 2013

Coroner Louise Hunt

Coroner Area Powys Bridgend and Glamorgan Valleys

Response Deadline ✓ from report 25 December 2013

Community health care and emergency services related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Critical low blood sugar information was disregarded by the ambulance operator, and the computer system's inability to process clinical details led to inappropriate CPR advice.

View full coroner's concerns

_ (1) Mr Johns son clearly confirmed the low blood sugar at the beginning of the call This critical important information was not factored into the advice provided to by the operator.

(2) The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails Valleys May May him him from him

Sent To

Department of Health and Social Care
Welsh Ambulance Service NHS Trust

Response Status

Linked responses 0 of 2

56-Day Deadline 25 Dec 2013

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 30"h 2013 commenced an investigation into the death of Winston Llewellyn Johns. The investigation concluded at the end of the inquest on 24 October 2013. The conclusion of the inquest was Mr Johns died from injuries sustained as a result of advised CPR during a 999 call on the 22n 2013. The low blood sugar of 1.4 reported during the 999 call was not factored into the decision making:

Circumstances of the Death

Mr Johns was a know diabetic. His son visited and found unrousable. He checked his blood sugar which was 1.4 (low). He called 999 and explained his father was diabetic and had a low blood sugar: His father was snoring: He was initially advised to maintain the airway in the chair his father was sitting in. The son described the breathing as normal. The son was then advised to put his father on the floor and commence CPR He did as advised. During CPR Mr Johns sustained a sternum fracture and multiple rib fractures. The paramedics arrived and gave a glucose drip t0 restore the blood sugar to 6.8. Mr Johns was admitted to hospital where he later died pneumonia caused by the rib and sternum fractures

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.