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A man who dialled 999 complaining of breathing problems and feeling faint died after an ambulance was sent to the wrong address.
Darryl Johnson, from Sandy in Bedfordshire, died from an untreated pulmonary thrombo-embolism – which is caused by a blood clot blocking a blood vessel in the lungs – an inquest found.
The 52-year-old was discovered dead at his home by colleagues after he didn’t show up to work on 24 February, 2025, but a coroner ruled he may have been found alive if an ambulance had been sent to the right address more than 15 hours earlier.
Coroner Emma Witting found Mr Johnson had called emergency services at 6.17am complaining of breathing problems and feeling faint, which are symptoms of pulmonary embolism.
Although an ambulance was sent to him just under an hour later, it was sent to 27a Market Square and not 27b Market Square, despite Mr Johnson giving the correct address.
A prevention of future deaths report revealed when there was no response at the neighbouring address, the ambulance crew called the fire service to force entry, but when no-one was found in the home the call response was closed.
Ms Witting raised concerns that the database used by the East of England Ambulance Services Trust is not up to date.
The ambulance trust told the coroner that it uses 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.
Although Ms Witting noted it is “not feasible for the database to be 100 per cent accurate and up to date” due to new builds and changes to property names and numbers, she stressed that Mr Johnson had lived at his address for 11 years and was paying council tax.
“It is, therefore, of concern why the database still did not have full details of his address,” she said in the report.
“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,” the coroner added.
An East of England Ambulance Service spokesperson said: “We would like to express our sincere condolences to the family and friends of Darryl Johnson.
“Following this incident, we carried out a full investigation and reviewed our practices to strengthen the processes we use when an address cannot be located on the Ordnance Survey Map Database, ensuring the correct address and relevant information are added to our systems.
“The findings of this investigation were shared with both the family and the coroner.”
