Grandmother Dies as Paramedics Complete Paperwork in Car Park
A 73-year-old grandmother passed away while paramedics filled out paperwork in a car park, a coroner's court has heard. Janet Noon, who had advanced Alzheimer's disease, died at Belvoir House care home in Norfolk on February 12, 2025, shortly after medical professionals decided against hospital transfer.
Decision to Monitor Rather Than Transport
The inquest at Norfolk Coroner's Court heard that care home staff had called 999 with concerns about Mrs Noon's condition. Following a phone consultation with Dr Wendy Clark, the pensioner's GP from Brundall Medical Partnership, it was agreed that hospital transfer was not in her best interests.
'If she is not gasping and she appears well in herself, it seems sensible to keep an eye on her,' Dr Clark said in a call transcript read to the court. 'It's not the best option at the moment for this lady to be moved to hospital.'
The GP explained that a urinary tract infection could reasonably explain Mrs Noon's symptoms and that hospital transfer risked causing unnecessary distress to the increasingly irritated patient.
Sudden Collapse and Death
Mere minutes after the decision was made, Mrs Noon suffered a catastrophic collapse as paramedics Francesca Cox and Philip Gough completed paperwork in the car park. Care home team leader Saaed Ahmed, who had checked on her moments earlier, ran outside to summon the paramedics back inside.
Domestic staff cleaning her room had raised an emergency alarm after noticing Mrs Noon become suddenly pale and stop breathing. The paramedics found her in pre-cardiac arrest, and despite intervention that briefly restored breathing, her condition rapidly deteriorated.
Mrs Noon died at 11.45am that day, approximately 15 minutes after being reviewed. Assistant coroner Robin Weyell described this as 'a very dramatic change in presentation,' while paramedic Francesca Cox agreed it was 'unexpected,' estimating the decline happened within about 15 minutes.
Family Concerns and Professional Defenses
Mrs Noon's sons, Jonathan and James Wedon, claimed the GP's decision represented a 'catastrophic failure.' In a statement read to court, Jonathan described the incident as 'horrible and distressing,' recalling: '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.'
However, Dr Clark and both paramedics maintained that no mistakes were made. They insisted the decision was clinically appropriate and based on Mrs Noon's comfort and well-being.
'We take a holistic view,' Dr Clark told the inquest via video call. '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.'
Paramedic Philip Gough added that while Mrs Noon was clearly unwell, her symptoms—including rapid heart rate and low oxygen levels—were consistent with various conditions, including infection. Both he and Dr Clark noted that even if a pulmonary embolism had been suspected, diagnosis and treatment would not have been available in the ambulance.
Contradictory Assessments and Care Concerns
A previous report by East of England Ambulance Service contradicted the paramedics' assessment, stating that 'based on the paramedics' assessment, the patient should have been transported to hospital.' The report added that 'reflective practice has been undertaken' as a result of their failure to act.
The inquest also heard concerns about Mrs Noon's care in the days preceding her death. Care worker Louise Dane testified that on February 11, Mrs Noon had refused food, drink, and medication while remaining in bed throughout the day. However, this was not escalated to a doctor at the time, given she had been eating the previous day.
Coroner's Conclusion and Family Tribute
Assistant coroner Robin Weyell concluded that Mrs Noon died from a pulmonary thromboembolism—a naturally occurring condition. While acknowledging areas where care could have been improved, he found none reached the threshold required to establish a link to causation.
'This was a naturally occurring condition,' Mr Weyell stated. '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.'
Mrs Noon, of Bluebell Way in Bradwell near Great Yarmouth, had been diagnosed with Alzheimer's disease in 2020 shortly after 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.'
Her husband Rick Noon said: 'The passing of Jan has left a void in many lives. Her only fault was that she would put herself last.'
