Jean Groves: Prevention of future deaths report
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Date of report: 23/01/2026
Ref: 2026-0036
Deceased name: Jean Groves
Coroner name: Johanna Thompson
Coroner Area: Norfolk
Category: Community health care and emergency services related deaths
This report is being sent to: Careline365 | Norfolk Swift Response
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 Careline365 Bowthorpe Employment Area 42 Barnard Road Norwich NR5 9JB 2 Norfolk Swift Response Norfolk County Council | |
| 1 | CORONER I am Johanna THOMPSON, Area Coroner for the coroner area of Norfolk |
| 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. |
| 3 | INVESTIGATION and INQUEST On 25 March 2025 I commenced an investigation into the death of Jean GROVES aged 75. The investigation concluded at the end of the inquest on 08 January 2026. The medical cause of death was: 1a) Acute Upper Gastrointestinal Haemorrhage 2) Ischaemic Heart Disease The conclusion of the inquest was: Natural causes |
| 4 | CIRCUMSTANCES OF THE DEATH Jean Groves had a complex health background, having had learning difficulties from an early age and dementia in more recent years. She was diagnosed with stomach ulcers in 2021 and had been prescribed appropriate medication to reduce stomach acid. She lived independently with support from carers and had a personal alarm to activate in case of emergency. She had been feeling unwell with diarrhoea and vomiting from 21st March 2025 and was provided with recognised medications by her local pharmacy. Her carer became concerned on 23rd March 2025 when her vomit was noted to be dark in colour. She was seen by a paramedic on that day who recorded her observations as normal. As she was also complaining of shoulder pain, she was advised to increase her pain relief medication to maximum dose. In the early hours of 24th March 2025, shortly before 5am she called her personal alarm service who in turn called the ambulance service with concern that she had fallen. The categorisation of the call and service demand was such that the ambulance arrived at her home shortly before 10am. It is recorded that the Community Service had no access details to enable them to attend after they had been contacted with a request to do so by the ambulance service under the “Access to the Stack” NHS digital initiative. Jean was sadly found deceased on arrival of the ambulance service at her home, 65 Manor Road, Long Stratton, Norwich, Norfolk on 24th March 2025, from the effects of excessive bleeding due to her underlying health condition. It is unknown whether her death could have been prevented had she received earlier medical attention. |
| 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: (brief summary of matters of concern) I have concerns that if emergency responders are not being provided with access details for vulnerable patients when providing support to the ambulance service under the NHS “Access to the Stack” initiative, this may lead to future deaths. |
| 6 | ACTION SHOULD BE TAKEN In my opinion 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 by March 09, 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 LeDeR – Learning Disabilities Reporting I have also sent it to Next of kin – cousin East of England Ambulance Service NHS Trust (EEAST) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 | Dated: 23/01/2026 Johanna THOMPSON Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH |