Brian Ingram

8 Oct 2025 · Coroner Andrew Cox · Cornwall and the Isles of Scilly

The coroner's concerns

1. misidentification of ambulance staff
“The family was under the impression that [the deceased] was attended upon by paramedics rather than ECAs”
2. family member excluded from clerking
“[the deceased] had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while [the deceased] was clerked in”
3. information sharing failure
“There was a conflict in the evidence as to whether a PCR was provided to MIU staff”
4. lack of physical assessment
“The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints”