Littleport man James Harrison was not the first body to be left on the floor of Ely ambulance station - it had happened twice before with other bodies being left in the back of ambulances.
But ambulance staff who left Mr Harrison in a body-bag on the station floor rather than take him through to the mortuary at Addenbrookes’ Hospital had ignored procedure and their actions could have “compromised forensic evidence” an inquest heard today.
Lawyers from the East of England Ambulance Service tried to prevent the hearing from looking at the circumstances which followed Mr Harrison’s death and to instead concentrate on how and why he died, a move rejected by coroner William Morris.
He said it was in the public interest to consider the “indignity, distress and possibility of forensic evidence being compromised” by the delays in transporting the body to Addenbrookes’.
Mr Harrison was found unconscious in the road outside Littleport’s fire station at around 5.15am on September 24 by a milkman,
Downham Market based ambulance crew David Glenton and Anne-Marie Poole were nearing the end of their night shift when they were called to help Mr Harrison. They made attempts to revive him but he was pronounced dead at 5.53am.
Mr Glenton and Miss Poole had about half-an-hour to go of their shift but said they would take the body through to the mortuary.
However, rapid responder Dharamendra Narotam suggested, with the agreement of police at the scene, to take the body to the ambulance station for an undertaker to collect.
Mr Glenton told the hearing he did not question the decision because it sounded like “common practice” and he thought different parts of the ambulance service had their own way of working.
At the station Mr Narotam laid a clean sheet on the floor before lying the body-bag down and covering it with another sheet. A police officer remained with the body throughout.
But the undertaker never came and a day crew from Ely eventually took Mr Harrison through to the Cambridge mortuary at 8.23am.
Coroner William Morris was concerned the delays could have compromised evidence - police initially thought he may have been injured in a road accident or assaulted - and so he ordered a full forensic post mortem.
The post mortem showed he had died of a drugs overdose. He had taken a cocktail of prescription drugs including anti-depressants and anti-insomnia pills.
Steve Hibbitt, paramedic and duty locality officer who carried out a report into the incident, which hit the headlines after a whistle blower contacted the Ely Standard, said Ely crews had left bodies on the floor on two previous occasions and in the back of an ambulance five times
Mr Hibbitt added: “The crew were not familiar with this procedure but were advised it was a normal local practice and several bodies had been left in this way before.
“The responder did not feel he was doing anything inappropriate and that he was doing something respectful by covering him in clean sheets.”
He explained it was not procedure to do this but local crews did sometimes act differently depending on police and coroner’s practices.
Mr Narotam, who has been removed from his rapid response role for a period and is now being managed by a qualified member of staff, said he had removed bodies from the “public gaze” in the past by taking them to the ambulance station.
Mr Harrison’s family only heard what had happened through press reports and Mr Hibbitt said lessons would be learned from the incident and there would be better communication with relatives in the future.
He said staff would all be made aware of the procedures for handling bodies to prevent this happening in the future.
Diane Harrison, Mr Harrison’s mother said her son, who had returned to live with her in October 2012 after his father died, would never have deliberately taken the overdose.
“He would not want to leave me on my own, he would not like anybody else to handle his father’s possessions. He didn’t mean to do it. I know that,” she said.
Coroner William Morris agreed the overdose was accidental and concluded his death was from mixed drugs intoxication.
Tracy Nicholls, Director of Clinical Quality at the East of England Ambulance Service NHS Trust said: “We apologise wholeheartedly to the family for the distress this incident has caused – it should never have happened. The Trust has carried out a full investigation into this matter and it is clear that incorrect decisions were made and the Trust’s procedures were not followed. As a result of this we immediately sent out an instruction to staff that such a practice is not acceptable and must not happen. The members of staff involved are subject to an ongoing investigation.
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