Darryl Johnson

I am Emma WHITTING, Senior Coroner for the coroner area of Bedfordshire and Luton Coroner Service

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.

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.

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.

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.