Edward Thomas WILSON · Prevention of Future Deaths report

On 03 January 2025 I commenced an investigation into the death of Edward Thomas WILSON aged 86. The investigation concluded at the end of the inquest on 04 June 2025. The conclusion of the inquest was that:

Narrative Conclusion - Died following the administration of salbutamol nebulisers in the context of unrecognised significant heart failure

Mr Wilson was attended at home by paramedics and on the second attendance transported to hospital by the ambulance service. The statements of the paramedics confirm that his observations were within normal ranges but that when auscultating his lung fields some fine crackles were heard from both lung bases without wheeze or stridor when attended at 11:43 hours on 28 December 2024. This was not on the face of it unreasonably diagnosed as a potential chest infection and was agreed by the GP AVS based at the hospital who dispensed antibiotics having taken into account the clinical history. When reattending at 19:35 hours Mr Wilson had a raised respiratory rate, a global wheeze on air, shortness of breath/difficulty breathing had worsened. The paramedics administered a salbutamol nebuliser as well as an atropium nebuliser which lasted the duration of the transit to hospital until cardiac arrest. The Consultant in Emergency Medicine stated that the withdrawal of blood pressure medication and administration of salbutamol nebulisers in the context of a known clinical history of significant heart failure contributed to the lowering of his blood pressure and repeated cardiac arrests on route to hospital.

The attending paramedics did not take the significant history of heart failure into account when making the decision to administer the salbutamol nebulisers which had a direct impact on the outcome by the lowering of Mr Wilson's blood pressure.