Category: Emergency services related deaths (2019 onwards)
This report is being sent to: Ordnance Survey
REGULATION 28 REPORT TO PREVENT DEATHS
THIS REPORT IS BEING SENT TO: 1 [REDACTED] CEO Ordnance Survey
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CORONER I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service
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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.
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INVESTIGATION and INQUEST On 12 March 2025 I commenced an investigation into the death of Darryl JOHNSON aged 52. The investigation concluded at the end of the inquest on 09 March 2026. The Narrative Conclusion of the inquest was that: The Deceased died from an untreated pulmonary thrombo-embolism.
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CIRCUMSTANCES OF THE DEATH The Deceased had resided at 27b Market Square in Sandy since 2015. After failing to attend his work as expected on 24 February 2025, at around 21.55 hours that evening, his co-workers discovered him deceased at his home. Police attended and confirmed his death at 23.09 hours. Investigations revealed that at 06.17 hours earlier that morning, the Deceased had called ambulance services complaining of breathing problems and feeling faint. An ambulance crew was despatched just under an hour later. However, even though he had provided the correct address, the ambulance call handler, relying on the Ordnance Survey Map Database, had directed the crew to attend a different address, namely, 27a Market Square. When there was no response at that address, the crew called the Fire Service to force entry, but when no-one was found to be there the call response was closed. Had the crew been sent to the right address, the Deceased may have been found alive, although it remained unclear whether his death would have been avoided.
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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) The East of England Ambulance Services Trust confirmed that their CAD system utilises an address and map database supplied by Ordnance Survey but that postal addresses listed in this database along with mapping coordinates to locate the property are not always accurate. Whilst it is it is accepted that it is not feasible for the database to be 100% accurate and up to date because it will take time for the system to be updated (as for example in the following situations: • New builds • Change of property name/number • Change of use for a property/dwelling) the Deceased had purchased his property over 11 years ago and had been paying Council Tax since that time. It is, therefore, of concern why the database still did not have full details of his address.
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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.
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YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 05, 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.
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COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person East of England Ambulance Service [REDACTED]
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.
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Dated: 10/03/2026 [redacted] Emma WHITTING Senior Coroner for Bedfordshire and Luton Coroner Service
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