Ambulance neglect caused man's death - inquest

A man died after "inexcusable" neglect by two Jersey ambulance workers, a coroner has said.

Frazer Irvine, 39, died of a heart attack on 18 March 2022 after he called 999.

Paramedic John Sutherland and ambulance technician Tom Le Sauteur were previously found guilty of failing to take reasonable care of him the night he died. That verdict was upheld at an appeal hearing.

Giving her conclusions at the end of the inquest on Friday, coroner Bridget Dolan KC accepted the findings of the trial. She said Mr Irvine was not given the care and attention he was entitled to and that he should not have died.

Ms Dolan agreed with evidence from a medical expert who said basic clinical care from Sutherland and Le Sauteur would probably have saved Mr Irvine's life.

She said: "Had Frazer received the care that should have been provided to him, including putting him in the recovery position to protect his airway and taking action to assess and manage his airway, he would not have suffered a cardiac arrest and he would not have died."

During the inquest, Sutherland and Le Sauteur suggested they might have been able to treat Mr Irvine differently had police responded to their calls for assistance quicker.

Ms Dolan said she found that argument "all too speculative", particularly given the crew's "wholesale lack of any urgency" throughout the events of the night.

She said it was reasonable for the ambulance crew to call the police but it was their lack of action when they arrived that caused Mr Irvine's death.

She said, regardless of the fact Mr Irvine was aggressive before the police arrived, "such gross neglect of the patient was inexcusable".

Addressing Mr Irvine's parents, Jim and Linda Irvine, Ms Dolan said she hoped the inquest had given them some answers.

The coroner said having to listen to the inactions that caused their son's death was "one of the most difficult things a parent could contemplate".

She apologised that, on top of their bereavement, they have had to go through several complex legal processes in Jersey, far away from their home in Scotland.

She also commended PC Polly Wilton, one of the police officers who attended to Mr Irvine and raised concerns about his breathing and colour that were initially "dismissed" by Le Sauteur.

After the inquest, Mr and Mrs Irvine said "there are no winners in this sort of situation".

They said: "Anyone who has lost a child will understand the pain that we carry with us every day.

"What makes Frazer's death harder to accept is that if timely, basic first aid had been attempted, he probably would have lived."

They welcomed the fact that the States of Jersey Ambulance Service (SOJAS) had accepted all the recommendations of an external Serious Incident Review, but they called on Jersey's politicians to make sure these changes would be adequately funded.

They said this was particularly important for the roll-out of body worn cameras, "not only for the protection of staff but in instances such as this for the protection of the patient".

The coroner also raised concerns about the adequacy of some of the ambulance service's policies and procedures and challenged the policies of the island's emergency call room.

She said she was concerned about the lack of SOJAS guidance, policy and training to assist staff when facing violence and aggression. She said there should be a system in place to crews when making difficult decisions, particularly when considering withdrawing care from violent patients.

She said she was concerned about the way information was ed in the island's emergency control room, and that a new draft policy did not touch on the issues with it.

She said she was also concerned that cue cards for R exist for ambulance staff use but aren't currently used in Jersey.

The Minister for Justice and Home Affairs, Deputy Mary Le Hegarat, extended her deepest condolences to the Irvine family.

She said: "Following Mr Irvine's death, the States of Jersey Ambulance Service has taken the opportunity to review policy, training and equipment arrangements with its staff."

She added the service remained dedicated to providing a safe, caring service for people in Jersey.

A spokesperson for the SOJAS said: "We are committed to learning from this tragic incident and from every opportunity that helps us to improve.

"That commitment is ongoing and central to how we serve our community – now and in the future."

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