Alfie Stone
14 Jan 2022 · Coroner Jean Harkin · Northamptonshire
The coroner's concerns
1. delayed oxygen delivery
“Evidence was heard at the inquest that paramedics were unable to deliver oxygen to [the deceased] for more than 15 minutes due to their concern that continuous fitting movements made it difficult for them to do so”
2. lack of buccal midazolam training
“In addition, the paramedics were not trained in the use of buccal midazolam, an anti-epileptic drug that can be given into the skin between teeth and cheek (side of mouth), onto the gums”
3. absence of alternative oxygenation methods
“No other form of oxygenation attempted such as bagging or the child being taken earlier to the ambulance to secure and deliver oxygen”
4. failure to perform suction and assess aspiration
“No suction attempted and the question was not asked of the parents as to whether the child had vomited”
5. insufficient paramedic training post-incident
“No evidence of training to the paramedics who attended and gave evidence following an independent Serious Incident Report and its agreed recommendations”
6. rejection of buccal midazolam recommendation
“East Midlands Ambulance Service not accepting the recommendation 3 within the report to carry and administer Buccal Midazolam when necessary”