October 13, 2026

Jane Lawrence: Prevention of future deaths report

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Date of report: 16/07/2026

Ref: 2026-0399

Deceased name: Jane Lawrence

Coroner name: Sonia Hayes

Coroner Area: Essex

This report is being sent to: Association of Ambulance Chief Executives

	REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
	THIS REPORT IS BEING SENT TO: 1. Association of Ambulance Chief Executives
1	CORONER I am Sonia Hayes, area coroner, for the coroner area of Essex
2	CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS]
3	INVESTIGATION On 20 February 2025 I commenced an investigation into the death of Jane LAWRENCE, AGE 60. The investigation has not yet concluded, and the inquest has not yet been heard.
4	CIRCUMSTANCES OF THE DEATH Jane Lawrence died in hospital on 14 February 2025. On 24 January 2025 Mrs Lawrence had an episode of severe hypoglycaemia with altered consciousness and was treated by a paramedic with 3 boluses of IV Glucose administered over a period of approximately 24 minutes and then complex carbohydrates in accordance with the JRCALC Guidelines. Mrs Lawrence then ate a meal and took her usual medication and went to sleep. Mrs Lawrence was found unresponsive the next morning, given emergency treatment and conveyed to hospital. Mrs Lawrence was found to have a profound neurological injury that did not respond to treatment.
5	CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – There is a risk of non-conveyance to hospital of a patient following an episode of Severe Hypoglycemia when following the JRCALC Guideline flowchart. (1) A paramedic first responder attended Mrs Lawrence for an episode of hypoglycemia with altered consciousness and administered treatment in accordance with the JRCALC Guidelines (JRCALC). The episode was considered within the flowchart in the JRCALC to be in the “Severe” range. Mrs Lawrence was treated with 3 boluses of IV Glucose in accordance with the JRCALC and then given complex carbohydrates. Mrs Lawrence was not conveyed to hospital or considered for further care and was given safety netting advice. The JRCALC flowchart for severe hypoglycaemia following completion of treatment states if the blood glucose has returned to >4mmol/L directs the healthcare practitioner back to “MILD” section of the flowchart. This then does not signpost or direct the healthcare practitioner to consider the pathway for patients who may require further care that is within a separate part of the JRCALC. There is a risk that a patient will not be considered for further care and particularly when they are prescribed Sulphonylureas with an increased risk of repeated episodes. (2) In the JRCALC the flowchart for Severe hypoglycaemia gives differing time thresholds for administration of IV Glucose than the administration of medication part of the JRCALC ad may lead to confusion. (3) East of England Ambulance Service NHS Trust issued a Red Patient Safety Notice on 9 July 2026 on the risk of non-conveyance highlighting further specific considerations as advised by the JRCALC and BNF so they are not missed. Other ambulance Trusts may not be aware of the potential discrepancy with the flowchart.
6	ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
7	YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by10 September 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
8	COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons · Family · East of England Ambulance Service Trust · East Suffolk and North Essex NHS Foundation Trust · Mid & South Essex NHS Foundation Trust · Pump House GP Surgery I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9	16 July 2026