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recurance

Fern Foster

7 Jun 2024 · Coroner Crispin Butler · Buckinghamshire

The coroner's concerns

  1. 1. delayed ambulance response to suspected ingestion of [REDACTED]

    “The process for triaging and prioritising ambulance attendance to an incident involving the suspected ingestion of [REDACTED] (intentionally or otherwise) does not provide sufficient opportunity for travel, attendance, conveyance to hospital for emergency treatment and/or provision of antidote treatment at scene, which may provide the only likely means of prevention of death where sufficient quantity has been ingested.”
  2. 2. absence of on-scene antidote administration for [REDACTED]

    “The carrying by ambulance services of appropriate antidote medication for on-scene administration (such as Methylene Blue), whilst trialled elsewhere, is not part of regional or national protocol. Swift access to this in circumstances where [REDACTED] is suspected, and timings mitigate against survival by the time of arrival at the nearest Emergency Department, could prevent future deaths in some cases.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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