Ali Mohammed Nazemi · Prevention of Future Deaths report

On 25/01/2024 I commenced an investigation into the death of Ali Mohammed Nazemi, aged 53. The investigation concluded at the end of the Inquest on 17/09/2024. The conclusion of the Inquest was that this was a death due to natural causes, the certified cause of death being 1a) Sepsis leading to multi organ failure; b) Aspiration pneumonia c) Acute stroke 2) Ex-intravenous drug use.

Mohammad Nazemi died from natural causes on 18th January 2024 in Pinderfields Hospital where he had been admitted from home the previous day having sustained an acute stroke and aspirated in the early morning. Paramedics were called some hours after the onset of symptoms. Mr Nazemi's transfer to hospital was delayed when he and the attending paramedics became trapped in the lift at his home address, the oxygen that he was receiving from the paramedics running out before they were rescued, and being restored when he was placed in the ambulance. On the balance of probabilities, he was so unwell by the time of the paramedics' first attendance that the delay in his arrival at hospital did not cause or contribute to the already inevitable outcome.

The lift that trapped Mr Nazemi and the attending paramedics is identified in an e-Worksheet generated by Schindler (copy attached) as a 20049625 MOD Replacement 6300.

The lift was examined by Schindler on the day of the incident, and it was found that “the uncontrolled movement device had been activated by persons using the lift”. The lift was being used by four paramedics who were transporting Mr Nazemi in a carry chair, the lift being too small to accommodate a stretcher. None of the paramedics were aware of having activated the uncontrolled movement device.

The evidence suggested that that was no way to reset the uncontrolled movement device once it had been activated, and that a call to the 24/7 helpline displayed in the lift could not help. Ultimately those trapped within the lift had to wait for the Fire & Rescue Service to break the lift door down.

Although Mr Nazemi was so ill that the 45 minute delay caused by the activation of the uncontrolled movement device made no difference to his outcome, there is a concern that others in his position may be seriously affected by the unintentional (and unnoticed) triggering of the uncontrolled movement device and by the fact that nothing apparently can be done to reverse any such unintentional triggering, such that those affected have to await rescue by the Fire & Rescue Service.