Ian Bean

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_

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

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?