Wayne Austin

I am Heath Westerman, H.M. Assistant Coroner, for the coroner area of Shropshire, Telford & Wrekin.

On 14 October 2024 I commenced an investigation into the death of Wayne AUSTIN The investigation concluded at the end of the inquest on 9 April 2026 The conclusion of the inquest was: Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024. Cardiopulmonary resuscitation was administered and West Midland Ambulance Service attended promptly. They began advanced life support which included the administration of Naloxone, a reversing agent used to deal with possible consumption of illicit drugs. He was then transferred to the emergency  department  of  The  Royal  Shrewsbury  Hospital,  Mytton  Oak  Road,  Shrewsbury, Shropshire where he died as the result of combined buprenorphine and alcohol toxicity. Drug and alcohol related.

Wayne Austin attended a meeting with his probation officer on 10 October 2024. He was asked if he had consumed any illicit drugs which he denied but confirmed he had drunk some cider. He collapsed and  CPR  was  undertaken  and  WMAS  called.  Two  ambulances  attended  and  paramedics  were informed by an unknown female outside that Wayne had earlier consumed crack cocaine. WMAS paramedics  therefore  began  ALS  and  sought  guidance  from  the  JRCALC  app  on  Naloxone administration.  They  found  the  guidance  confusing  and  experienced  difficulties  identifying  and accessing  the  correct  guidance  and  so  opened  the  first  available  tab  ’Dosage  table:  IV/IO  – Respiratory arrest/depression’ which confirms an initial dose of 400mg then further doses of 400mg every three minutes until a maximum of 4000mg delivered. The paramedics provided a first dose of 400mg at 14.45 with further 400mg doses at 14.50, 14.55, 15.00 and 15.05 when a return of spontaneous  circulation  was  achieved  and  medication  was  paused.  No  further  Naloxone  was administered and Wayne was transferred to The Royal Shrewsbury Hospital. They could not comply with administrating doses every three minutes due to other competing tasks such as continuing with ALS, administering oxygen, adrenaline and sodium chloride. The paramedics did not open and apply the correct tab, the JRCALC app has five tabs for Naloxone, the fourth tab being the appropriate tab in the circumstances ‘ Dosage table: IV/IO Cardiac arrest (where opioid toxicity is the likely cause) this confirms an initial dose

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) Difficulties in locating the appropriate tab for cardiac arrest (where opioid toxicity is the likely cause) on the JRCALC app for Naloxone meant it was missed and not applied (2) Inability of attending paramedics to comply with the guidelines for Respiratory arrest/depression due  to  other  competing  tasks  and  therefore  certainly  a  complete  inability  to  comply  with  the guidelines for cardiac arrest (where opioid toxicity is the likely cause) making them potentially unrealistic. (3) WMAS ambulances only carry a box of 10 Naloxone 400mg vials per ambulance which means that one ambulance attending a situation such as Wayne’s would be insufficient to deal with the circumstances, as would two ambulances. It would mean that three ambulances are required to comply with cardiac arrest (where opioid toxicity is the likely cause).

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.