Source · Prevention of Future Deaths

Winston Llewellyn Johns

Ref: 2013-0279 Date: 30 Oct 2013 Coroner: Louise Hunt Area: Powys Bridgend and Glamorgan Valleys Responses identified: 0 / 2 View PDF

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.

Date 30 Oct 2013
56-day deadline 25 Dec 2013
Responses identified 0 of 2
Community health care and emergency services related deaths

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

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.

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Report details

Reference
2013-0279
Date of report
30 October 2013
Coroner
Louise Hunt
Coroner area
Powys Bridgend and Glamorgan Valleys

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Dec 2013.

Sent to

Department of Health and Social Care
Welsh Ambulance Service NHS Trust

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