Drew John GREAVES-PIMBLETT · Prevention of Future Deaths report

On 25 March 2025 I commenced an investigation into the death of Drew John GREAVES-PIMBLETT aged 26. The investigation concluded at the end of the inquest on 08 January 2026. The conclusion of the inquest was that:

Drew Drew John Greaves-Pimblett died as a result of:

1a Sudden Unexpected Death in Epilepsy (SUDEP)

b. Epilepsy

Natural Causes

Drew John Graves-Pimblett was a 26 year old gentleman who had a medical history of epilepsy. On 22 March 2025, Drew was found unresponsive on the floor of the bathroom of his home address. At 14:11 hours a call was made to the North West Ambulance Service (NWAS), the information provided to the call handler was that Drew was found on the floor unresponsive and not breathing. The call was assessed as a category 1 emergency and an ambulance was allocated at 14:12 hours. As a result of the on-going conversation and confirmation of the fact he was not breathing, at 14:15 hours it was established Drew was epileptic, cold to touch and his finger nails, lips and face were grey. It was also proving difficult for him to be turned over onto his back so he remained on his front. As a result of this information, in accordance with the NWAS pathway, the call handler deemed Drew had not ‘just died’ and so resuscitation would not be effective. At 14:16 hours the ambulance was stood down and the police notified. At 14.43 hours the police attended and one officer noted Drew was still warm to the touch and so CPR was commenced. The other officer present observed Drew’s lips were blue/purple and swollen and his chest was quite stiff making CPR difficult. NWAS were contacted again, and an ambulance arrived at 14:44 hours and Drew was pronounced deceased at 14:46 hours on the same day.

A review of the first call made to NWAS revealed the call handler should not have down-graded the call and should not have stood the ambulance down until further probing questions were asked. There were no questions asked to establish how cold Drew was (‘stone cold’ or otherwise), how it was established he was not breathing, whether anyone else was available to help turn Drew onto his back and how stiff Drew was to establish whether rigor mortis had set in. It is impossible to know whether, after the probing questions were asked, the call handler would have reached the same conclusion or whether CPR would have been advised. The absence of the probing questions being a missed opportunity. It would be pure speculation to reach a conclusion that had CPR been carried out it would be a different outcome for Drew. NWAS found the appropriate standard of the call had not been achieved. In all the circumstances it is more likely that not Drew died of natural causes.

Though a telephone triage is always challenging and subjective, there appears to be a gap in the national pathways for call handlers. Consideration as to further guidance and assistance to call handlers on probing questioning for fundamental aspects such as breathing and where and how to best show how cold the body is. If someone is not breathing to ask how they know and/or techniques such as head to the chest, where to take a pulse etc. for the call handler to make a more informed decision as to whether someone is breathing and if CPR is required. When a call is made to NWAS, often it is by someone not thinking straight and so specific questions on breathing and general presentation may be of assistance in assessing the call.