North West Ambulance Service NHS Trust
NHS / Health Body
Disputed
NWAS argues that the treatment provided to Mr. Wilson adhered wholly to national guidelines produced by JRCALC, and there were no contraindications to the use of salbutamol despite Mr. Wilson’s medical history. (AI summary)
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Dear Ms Devonish
Regulation 28 Report – Inquest Touching the Death of Edward Thomas Wilson
I write further to your Prevention of Future Deaths Report dated 5 June 2025, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Mr Wilson.
I am aware that you will share my response with Mr Wilson’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes.
Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter I will address those concerns as far as I am able.
The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson’s blood pressure.
Upon receipt of the Regulation 28 report a decision was made to undertake a retrospective Specialist Review into the treatment and care provided to Mr Wilson. NWAS was not aware of any concerns regarding Mr Wilson’s care prior to the conclusion of the inquest, and the witness statements provided did not highlight any failures in practice or procedure. NWAS was not present or represented at the inquest and did not have Interested Person status to the proceedings.
The Specialist Review has been carried out by an NWAS Sector Clinical Lead, and a copy of the Review is attached to my letter for completeness. However, I have summarised the key findings below which I hope is of assistance.
The assessment of Mr Wilson was conducted in a timely and structured way. Mr Wilson’s clinical presentation suggested a primary respiratory issue.
Auscultation of Mr Wilson’s lungs revealed a “global wheeze” meaning that wheezing could be heard throughout his lungs. The treatment of wheeze and associated shortness of breath was commenced using oxygen driven nebulised salbutamol 2.5mg in 2.5ml at 19:40 hours. A further repeat dose of salbutamol was issued concurrently with Ipratropium Bromide at 20:12 hours.
The Specialist Review indicates that treatment of Mr Wilson’s shortness of breath, in the context of pulmonary wheeze, should include the use of salbutamol driven by oxygen as outlined below:
Salbutamol
JRCALC (Joint Royal Colleges Ambulance Liaison Committee) provides a national framework of standards and treatment guidelines for the provision of pre hospital care as delivered by ambulance services. Paramedics, prior to issuing any medication, are advised to consult JRCALC to ensure the appropriateness of their treatment plan. The Specialist Review concludes that Salbutamol would have been indicated for Mr Wilson as he was suffering with expiratory wheeze associated with a lower airway cause, presumed to be infection. There was no absolute contraindication for using Salbutamol. The Review acknowledges that Mr Wilson had a recorded history of hypertension and therefore a long dosing interval should be used. A dose interval of 5 minutes is advocated by JRCALC, however in Mr Wilson’s case a dose interval of 32 minutes is recorded between both administrations of Salbutamol. The use of salbutamol in the treatment of Mr Wilson’s illness was indicated and substantiated as appropriate by the national guidelines.
The Specialist Review has concluded that the treatment afforded to Mr Wilson adhered wholly to the national guidelines produced by JRCALC and I hope this addresses the concerns you have raised. There were no contraindications to the use of salbutamol despite Mr Wilson’s medical history. Therefore, any risk resulting from adherence to these guidelines is born at a national scale and should be directed to JRCALC directly.
I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, .
Regulation 28 Report – Inquest Touching the Death of Edward Thomas Wilson
I write further to your Prevention of Future Deaths Report dated 5 June 2025, which was issued to North West Ambulance Service (“NWAS”) following the conclusion of the inquest touching the death of Mr Wilson.
I am aware that you will share my response with Mr Wilson’s family, and I firstly wish to express my sincere condolences to them. NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes.
Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future. By this letter I will address those concerns as far as I am able.
The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson’s blood pressure.
Upon receipt of the Regulation 28 report a decision was made to undertake a retrospective Specialist Review into the treatment and care provided to Mr Wilson. NWAS was not aware of any concerns regarding Mr Wilson’s care prior to the conclusion of the inquest, and the witness statements provided did not highlight any failures in practice or procedure. NWAS was not present or represented at the inquest and did not have Interested Person status to the proceedings.
The Specialist Review has been carried out by an NWAS Sector Clinical Lead, and a copy of the Review is attached to my letter for completeness. However, I have summarised the key findings below which I hope is of assistance.
The assessment of Mr Wilson was conducted in a timely and structured way. Mr Wilson’s clinical presentation suggested a primary respiratory issue.
Auscultation of Mr Wilson’s lungs revealed a “global wheeze” meaning that wheezing could be heard throughout his lungs. The treatment of wheeze and associated shortness of breath was commenced using oxygen driven nebulised salbutamol 2.5mg in 2.5ml at 19:40 hours. A further repeat dose of salbutamol was issued concurrently with Ipratropium Bromide at 20:12 hours.
The Specialist Review indicates that treatment of Mr Wilson’s shortness of breath, in the context of pulmonary wheeze, should include the use of salbutamol driven by oxygen as outlined below:
Salbutamol
JRCALC (Joint Royal Colleges Ambulance Liaison Committee) provides a national framework of standards and treatment guidelines for the provision of pre hospital care as delivered by ambulance services. Paramedics, prior to issuing any medication, are advised to consult JRCALC to ensure the appropriateness of their treatment plan. The Specialist Review concludes that Salbutamol would have been indicated for Mr Wilson as he was suffering with expiratory wheeze associated with a lower airway cause, presumed to be infection. There was no absolute contraindication for using Salbutamol. The Review acknowledges that Mr Wilson had a recorded history of hypertension and therefore a long dosing interval should be used. A dose interval of 5 minutes is advocated by JRCALC, however in Mr Wilson’s case a dose interval of 32 minutes is recorded between both administrations of Salbutamol. The use of salbutamol in the treatment of Mr Wilson’s illness was indicated and substantiated as appropriate by the national guidelines.
The Specialist Review has concluded that the treatment afforded to Mr Wilson adhered wholly to the national guidelines produced by JRCALC and I hope this addresses the concerns you have raised. There were no contraindications to the use of salbutamol despite Mr Wilson’s medical history. Therefore, any risk resulting from adherence to these guidelines is born at a national scale and should be directed to JRCALC directly.
I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust’s Deputy Director of Corporate Affairs, .