Christopher James Locke · Prevention of Future Deaths report

On the 11th August 2022 I commenced an investigation into the death of Christopher James Locke. The investigation concluded at the end of the inquest on the 24th of August 2023.

The medical cause of death is
1a) hypoxic ischaemic encephalopathy
1b) cardiac arrest
1c) cardiac arrythmia in a man with a fatty heart who had sustained a blow to the head

The conclusion of the inquest as to how Mr Locke came to his death was a narrative conclusion and is as follows:-

The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased’s death

The deceased was Christopher James Locke and he was pronounced dead on the 29th October 2021 at Morriston Hospital, Swansea. The cause of death was hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac.

Christopher was admitted to Morriston Hospital via UHW Hospital Cardiff on the 23rd October 2021 having sustained a cardiac arrest at the Lord Cradoc public house, Port Talbot during the evening of the 21st of October 2021. The cause of the cardiac arrest was found to be a cardiac arrhythmia. The staff at the Lord Cradoc called 999 and followed the instructions provided by the Emergency Medical Dispatcher (EMD). The EMD did not instruct the staff to undertake CPR. Christopher’s circulation was restored 12 minutes after the arrival of the paramedics, who arrived 8 minutes after the commencement of the call. It was therefore estimated that Christopher had been without oxygen for at least 20 minutes. Christopher died from a brain injury caused by this lack of oxygen.

1. In a pub environment there is a greater chance for the public to sustain injuries that requires emergency treatment
2. Ordinary bystanders’ ability to administer emergency treatment may be hindered by their own consumption of alcohol
3. Whilst the primary responsibility of staff is to comply with EMD directions they are deprived of the opportunity to provide lifesaving treatment in circumstances that warrant it if that training is not offered
4. Staff would not know the circumstances that warrant it without the benefit of CPR training.