LESSONS have been learned after two ambulance staff prematurely pronounced a woman’s death near Kidlington, a coroner said.

Ambulance technicians from a specialist contractor said Caron Kiernan – commonly known as Keshava Devi Dasi – was dead before attempting resuscitation, Oxfordshire Coroner’s Court heard.

An expert called their actions “clinically negligent,” but said they did not contribute to the 55-year-old’s death on December 19 last year.

The inquest heard how former teacher Mrs Kiernan – married to Oxford Centre for Hindu Studies director Shaunaka Rishi Das for 27 years – suffered from chronic fatigue syndrome. She became depressed in March last year and had talked about killing herself.

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Mr Rishi Das, 53, realised his wife was missing late on December 18 last year.

He found her with the help of neighbours in a field near their home in High Street, Charlton-on-Otmoor. It was believed she had been in a nearby river.

She was soaking wet, very cold and had a deep cut to her left wrist but still responsive, the inquest was told.

Mr Rishi Das then dialled 999, shortly after midnight. Police officers arrived and helped treat her, believing she was still alive.

When UK Specialist Ambulance Service (UKSAS) staff Jim McMahon and Roy Human arrived, they took a pulse and pronounced her dead.

Oxford Mail:

Caron Kiernan's husband Shaunaka Rishi Das

PC Steven Hitchins said in a statement he was surprised they were not carrying life-saving equipment and did not try to resuscitate her. He said they only began CPR after being asked to by police officers.

The technicians’ ambulance became stuck in mud and a South Central Ambulance Service (SCAS) vehicle eventually arrived, taking her to the John Radcliffe Hospital, where she was pronounced dead at 6.45am.

Consultant anaesthetist Dr David Sutton said there had been “inappropriate recognition of life extinct” by the UKSAS staff and they should have first tried to resuscitate Mrs Kiernan. He said: “That doesn’t comply with [national] guidelines. That, in my opinion, was clinical negligence.”

But he added: “Once she went into cardiac arrest in those conditions the chances of survival were pretty much zero.”

Coroner Darren Salter said the wet, dark conditions had made it more difficult for ambulance staff.

He added: “There were significant shortfalls in the initial response. I’m satisfied that all concerned have conducted reviews and learned lessons where appropriate.”

A post mortem found she died of hypothermia, compounded by the loss of blood from her cut wrist. After a two-day inquest ended on Thursday, the coroner recorded a verdict of suicide.

A SCAS spokeswoman said: “SCAS undertook an investigation following this incident from which some learning was identified and this has been shared with staff. Actions that were raised have been subsequently completed.”

Mr Rishi Das said after the inquest: “I will always remember my wife as a devotee to God.

“She was a very spiritual, graceful and gracious person and she led a life of good example.”

 

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