Source · Prevention of Future Deaths
Winston Llewellyn Johns
Ref: 2013-0279
Date: 30 Oct 2013
Coroner: Louise Hunt
Area: Powys Bridgend and Glamorgan Valleys
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner noted that crucial low blood sugar information was not considered in the advice provided by the ambulance operator. Additionally, the ambulance service's computer program did not account for critical clinical information, leading to incorrect CPR advice.
Date
30 Oct 2013
56-day deadline
25 Dec 2013
stated in the report
Responses identified
0 of 2
Coroner's concerns
The coroner noted that crucial low blood sugar information was not considered in the advice provided by the ambulance operator. Additionally, the ambulance service's computer program did not account for critical clinical information, leading to incorrect 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
(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 (stated in the report).
Sent to
- Department of Health and Social Care
- Welsh Ambulance Service NHS Trust