Winston Llewellyn Johns · Prevention of Future Deaths report

On 30th May 2013 I 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 22nd May 2013. The low blood sugar of 1.4 reported during the 999 call was not factored into the decision making.

Mr Johns was a know diabetic. His son visited him and found him 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 to restore the blood sugar to 6.8. Mr Johns was admitted to hospital where he later died from pneumonia caused by the rib and sternum fractures

(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 him 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.