Ian Thomas Trevor BEAN · Prevention of Future Deaths report

On 26 April 2018, an investigation was opened into the death of Ian Thomas Trevor Bean who died on 14/4/18 at Liskeard in Cornwall. The matter concluded with an inquest held on 9/10/19. Mr Bean was found to have died from:
1A) multidrug toxicity
2) chronic obstructive pulmonary disease.
The conclusion recorded was that Mr Bean died by suicide.

Mr Bean had become agitated and distressed at his home address on the date of his death. He had telephoned his father who lived in Nottingham and to whom he had not spoken for two years. He told his father that he had failed him as a parent and that he was dying from an overdose of morphine (Oramorph) he had taken which was prescribed to him.

His father rang East Midlands Ambulance Service to request an ambulance for his son in Cornwall. In error, the ambulance was directed to his father's address in Nottingham.

It was accepted at inquest that this error was not causative of the death as paramedics and police were also called to the address in Cornwall. Nevertheless, it was felt that this was an error of such a fundamental nature that action should be taken to ensure deaths did not occur in the future from a similar oversight.

An ambulance was wrongly dispatched to the address of Mr Bean’s father in Nottingham rather than to Mr Bean in Cornwall.