Grandmother, 73, died whereas paramedics stuffed out paperwork in automotive park, inquest hears

A 73-year-old grandmother died while paramedics filled out paperwork in a car park, an inquest has heard. 

Janet Noon passed away after both a GP and paramedics agreed it was in her ‘best interests’ to keep an eye on her instead of transferring her to the hospital. 

Mrs Noon, who had advanced Alzheimer’s disease, was assessed by staff at Belvoir House care home in Norfolk, who had called 999 with concerns about her condition.  

However, after a phone consultation with Dr Wendy Clark, the pensioner’s GP, it was decided the 73-year-old would not be taken to hospital. 

The following call transcript of the GP, who worked at Brundall Medical Partnership, was read to Norfolk Coroner’s Court. 

‘If she is not gasping and she appears well in herself, it seems sensible to keep an eye on her…,’ Dr Clark said. 

‘Staff should monitor her Sats and observations every hour, and I will check her urine and assess her when I arrive.

‘It’s not the best option at the moment for this lady to be moved to hospital.’

However, Mrs Noon died soon after at the care home on February 12, 2025. Her sons, Jonathan and James Wedon, claimed the GP’s decision was a ‘catastrophic failure’.  

Meanwhile, paramedics Francesca Cox and Philip Gough, as well as Dr Clark, have maintained that no mistakes were made in the run-up to the pensioner’s death. 

They insist the decision was clinically appropriate and based on the 73-year-old’s comfort and well-being. 

Giving evidence via video call, Dr Clark stood by her decision, adding she felt it was ‘appropriate’ and in the ‘best interest’ of Mrs Noon.  

She said a urinary tract infection could have reasonably explained the pensioner’s symptoms, the inquest heard. 

Dr Clark also added that taking Mrs Noon to the hospital risked causing her unnecessary distress, given she was becoming irritated. 

‘We take a holistic view,’ the GP told the inquest. 

‘If a patient is likely to become very distressed being taken out of a familiar environment, we have to weigh up what is best for their comfort and safety.’

But mere minutes after the decision was made, Mrs Noon suffered a catastrophic collapse as paramedics filled out notes in the car park.  

Care home team leader Saaed Ahmed, who called the ambulance, told the court he had checked on her before the crew stepped outside.

Moments later, an emergency alarm was raised by domestic staff cleaning her room, who noticed her become suddenly pale and stop breathing.

Mr Ahmed ran out into the car park to call Ms Cox and Mr Gough back inside, where they found Mrs Noon in pre-cardiac arrest, the court heard. 

And her condition rapidly deteriorated despite briefly regaining the ability to breath after intervention. 

In a statement read to the court, her son Jonathan described the incident as ‘horrible and distressing’. He said: ‘She was gasping for breath, grabbing at the curtains.’

‘I pleaded for them to do something so she did not suffer, but it felt like they were just watching her.’

Mrs Noon died at 11.45am that day, around 15 minutes after she was reviewed. Her sudden deterioration came as a shock to those treating her, the inquest was told.  

‘That is a very dramatic change in presentation,’ assistant coroner Robin Weyell said.

Ms Cox agreed it was ‘unexpected’, estimating the decline happened within around 15 minutes. 

However, both paramedics maintained that their original decision had been the right call.  

Mr Gough added that while Mrs Noon was clearly unwell, her symptoms – including a rapid heart rate and low oxygen levels – were consistent with a number of conditions, including infection.

Both he and Dr Clark said that even if a pulmonary embolism had been suspected, diagnosis and treatment would not have been available in the ambulance.

A previous report by East of England Ambulance Service said, based on the paramedics’ assessment, ‘the patient should have been transported to hospital’. 

It also added that ‘reflective practice has been undertaken’ as a result of their failure to act.

Mrs Noon’s family raised concerns about her care in the days before her death, the inquest heard.

Care worker Louise Dane told the court that on February 11, Mrs Noon had refused food, drink and medication and remained in bed throughout the day.

However, this was not escalated to a doctor at the time, given she had been eating the previous day.

Mrs Noon, of Bluebell Way in Bradwell, near Great Yarmouth, had been diagnosed with Alzheimer’s disease in 2020 shortly after entering retirement.

Her family described the former nurse, special constable and Matthew Project charity worker as someone who ‘gave so much and asked for so little’.

‘The passing of Jan has left a void in many lives. Her only fault was that she would put herself last,’ her husband Rick Noon, said. 

Assistant coroner Robin Weyell concluded that Mrs Noon had died as a result of a pulmonary thromboembolism – a naturally occurring condition.

Mr Weyell said that while there had been areas where care could have been improved, none reached the threshold required to establish a link to causation.

‘This was a naturally occurring condition,’ he said, noting that the care staff, paramedics and GP were not to blame.

‘The concerns raised have been fully explored, but I do not find that any of those matters caused or contributed to Janet Noon’s death.’