Overview
- Assistant coroner Robin Weyell concluded Friday that 73-year-old Janet Noon died from a pulmonary thromboembolism and that the death was not preventable.
- He rejected claims by her sons about failures by care staff, the ambulance crew, and her GP, finding no evidence these actions caused or contributed to her death.
- On February 12, 2025, paramedics consulted GP Dr Wendy Clark by phone and agreed to monitor the advanced dementia patient in the care home rather than transfer her to hospital.
- Minutes after the crew stepped outside to complete notes, staff raised the alarm as Mrs Noon collapsed and died at 11:45am, and CPR was not attempted under her Respect form.
- An internal East of England Ambulance Service report later said she should have been taken to hospital, though clinicians told the court an ambulance could neither diagnose nor treat a suspected clot.