Mr Jakupi, a 67-year-old man with hypertension, hypercholesterolaemia, type 2 diabetes and smoking history, called emergency services at 5:12am reporting shortness of breath. Ambulance paramedics were dispatched but could not locate him at the caravan park despite two attempts because his site number was initially unknown, poor lighting, lack of clear site numbering, and obscured caravan number delayed finding him by 43 minutes. He was found unresponsive at 5:55am and declared deceased at 6:00am. The cause of death was unascertained natural causes; without autopsy confirmation, it is unclear whether earlier paramedic arrival would have changed the outcome. System improvements in emergency address identification and caravan park signage have since been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Ambulance paramedics unable to locate patient at caravan park initially
Site number not ascertained from emergency call
Caravan park poorly lit with no obvious site plan and unclear site numbering
Patient's caravan number obscured by vehicles
ESTA dispatcher protocol did not include question about type of residence
Emergency contact numbers not visible to paramedics
43-minute delay between emergency call and paramedics locating patient
Coroner's recommendations
That ESTA protocols be amended to include an additional question after asking for the address such as 'What type of residence is that?' or 'Is that a house or a flat or something else?'
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