Romeo Esposito

I am Dr Simon Fox KC Assistant Coroner for Area of Avon

I held an Inquest in the death of Romeo Miles Esposito on 14-15 th March 2024. The conclusion of the inquest was –   Romeo was found unconscious in bed at home. Emergency staff attended but stopped resuscitation and assessed Romeo as having died. This proved incorrect – he continued to make respiratory effort and his heart beat returned for some time before resuscitation resumed. However, he died in hospital the next day from a brain injury consequent upon his cardiac arrest.

See below.

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. Romeo was making respiratory effort for about an hour after ROLE at 0952 hours and resuscitation being resumed at 1049 hours;His family raised their concerns regarding this with SWAS clinical stff on a number of occasions thoughout this period;Staff repeatedly ascribed the respiratory effort to “a release of air ”, as opposed to a change in Romeo’s clinical condition which required further clinical assessment; There was no evidence to confirm that clinical staff have been warned or trained not to use “a release of air” as an explanation for respiratory effort or a reason to avoid further clinical assessment.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.