Jane Walker · Prevention of Future Deaths report

On 11 August 2020 an investigation was commenced into the death of Jane Walker (DOB 3 April 1968) who died on 8 August 2020. The investigation concluded at the end of the inquest on 13 March 2024. The conclusion of the inquest was accident.

The circumstances of the death are as follows :-

On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch.

Jane was administered morphine for pain relief at the slip way by the paramedics. Administering such opioid medication takes time in that a cannula must first be inserted and once administered the morphine can take up to 15 minutes to be effective.

Evidence was heard at the Inquest that there are alternative analgesics which can be administered much more quickly, have a much quicker impact and can be easier to remove when required. Example of such is mucosal fentanyl lozenge. This can be administered by placing the lozenge (on a stick) into the patient’s mouth, which takes effect very quickly and which can be removed quickly if required. It can be considered a safe and rapid method of delivering pre-hospital analgesia and is used by the military. It is not, however, available to paramedics.

I am concerned that the unavailability of such analgesics to paramedics (in England as well as Wales) to assist patients who require immediate pain relief in the context of it reducing stress on the body, providing easier and potentially faster extrication and patient handling, and improving breathing, where time is of the essence for medical treatment, to reflect a risk of deaths into the future.

Pursuant to controlled drug legislation paramedics are not currently permitted to administer such analgesics. Whilst matters of health are devolved to Wales, controlled drug legislation in this context is not a devolved matter to Wales, hence this Report to the Home Secretary. I am aware that The Medicines Act 1968 and/or other controlled drug legislation would require amendment to allow paramedics to administer such analgesia.