Janet Noon, 73, died at a Norfolk care home after paramedics and GP decided against hospital transfer, but a coroner has ruled her death was from natural causes and could not have been prevented
A grandmother passed away while paramedics were completing paperwork in the car park, minutes after a GP advised against transferring her to hospital, an inquest has heard.
Janet Noon, 73, died after paramedics and a GP concluded it was in her “best interests” to monitor her condition rather than admit her to hospital.
Mrs Noon, who suffered from advanced Alzheimer’s disease, was assessed after care home staff dialled 999 over concerns about her deteriorating health.
However, following a telephone consultation with Mrs Noon’s GP, Dr Wendy Clark, of Brundall Medical Partnership, a decision was taken not to transfer her to hospital.
In a call transcript read aloud to the court, Dr Clark told paramedics at the scene: “If she is not gasping and she appears well in herself it seems sensible to keep an eye on her … 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.”
Mrs Noon died shortly afterwards at Belvoir House care home in Brundall, Norfolk, on February 12, 2025, Norfolk Coroner’s Court was told. Her sons, Jonathan and James Wedon, have argued the decision represented a “catastrophic failure”.
Paramedics Francesca Cox and Philip Gough, together with GP Wendy Clark, have maintained that no errors were made, insisting the decision was clinically sound and focused on Mrs Noon’s comfort and wellbeing.
Giving evidence via video link, Dr Clark said she stood by her decision, stating: “Yes, at that point in time I felt it was appropriate and a best interest decision for Mrs Noon.”
She informed the court that Mrs Noon’s symptoms could reasonably have been attributed to a urinary tract infection, and acknowledged that taking her to hospital risked causing unnecessary distress given she was becoming agitated.
Dr Clark said: “We take a holistic view. 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.”
Yet within minutes of that decision being made, Mrs Noon suffered a catastrophic collapse while the paramedics were completing paperwork in the car park.
Care home team leader Saaed Ahmed, who had called the ambulance, told the court he had checked on her before the crew stepped outside.
Shortly afterwards, an emergency alarm was triggered by domestic staff cleaning her room, who noticed her suddenly turn pale and stop breathing.
Mr Ahmed rushed out to the car park to summon paramedics Ms Cox and Mr Gough back inside. The court heard they returned to discover Mrs Noon in pre-cardiac arrest – described as “pale, unresponsive and not breathing”. Although she briefly resumed breathing following intervention, her condition deteriorated rapidly.
Jonathan Wedon described the scene as “horrible and distressing” in a statement read to the court. “She was gasping for breath, grabbing at the curtains,” he said. “I pleaded for them to do something so she did not suffer, but it felt like they were just watching her.”
Mrs Noon passed away at 11.45am, roughly 15 minutes after being reviewed. The inquest heard that her sudden deterioration came as a shock to those treating her. “That is a very dramatic change in presentation,” assistant coroner Robin Weyell said.
Ms Cox concurred that it was “unexpected”, estimating the decline had occurred within approximately 15 minutes. Despite this, both paramedics stood by their original decision as correct.
Mr Gough added that while Mrs Noon was clearly in a poor state, her symptoms – including a rapid heart rate and low oxygen levels – were consistent with a number of conditions, amongst them infection.
Both he and Dr Clark informed the court that even had a pulmonary embolism been suspected, diagnosis and treatment would not have been possible in the ambulance.
A previous report by East of England Ambulance Service stated that, based on the paramedics’ assessment, “the patient should have been transported to hospital” and that “reflective practice has been undertaken” as a result of their failure to act. The inquest also heard concerns raised by Mrs Noon’s family regarding her care in the days leading up to her death.
Care worker Louise Dane told the court that on February 11, Mrs Noon had refused food, drink and medication and had remained in bed for the entirety of the day.
However, this was not referred to a doctor at the time, given that she had been eating the day before. Mrs Noon, of Bluebell Way in Bradwell, near Great Yarmouth, had been diagnosed with Alzheimer’s disease in 2020, shortly after she retired.
A former nurse at the James Paget Hospital, special constable and charity volunteer with the Matthew Project, her family described her 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.”
Assistant coroner Robin Weyell concluded that Mrs Noon had died as a result of a pulmonary thromboembolism – a naturally occurring condition.
Reviewing the evidence, Mr Weyell acknowledged that while certain aspects of her care could have been handled better, none met the threshold needed to establish a link to causation.
“This was a naturally occurring condition,” he said, adding that the care staff, paramedics and GP bore no responsibility. 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.”
