Ambulance attended wrong address in fatal case

A man who died of a blood clot had called an ambulance but it went to the wrong address, a coroner has revealed.

Darryl Johnson, 52, was found dead at his home in Sandy, Bedfordshire, by colleagues who were concerned he had not turned up to work.

Bedfordshire coroner Emma Whiting said in a prevention of future deaths report: "Had the crew been sent to the right address, the deceased may have been found alive, although it remained unclear whether his death would have been avoided."

Ordnance Survey, which supplies the East of England Ambulance Service with maps and addresses, said it was carrying out a review into the incident.

Johnson's co-workers discovered him at about 21:55 GMT on 24 February 2025 at his home address 27b Market Square.

Bedfordshire Police attended and confirmed his death at 23:09, and an inquest in March 2026 concluded he died from an untreated pulmonary thrombo-embolism.

Johnson had phoned for an ambulance at 06:17 on 24 February and complained of breathing problems and feeling faint, the coroner said.

In the report Whiting said: "An ambulance was dispatched just under an hour later.

"However, even though he had provided the correct address, the ambulance call handler, relying on the Ordnance Survey Map Database, had directed the crew to attend a different address, namely 27a Market Square," she wrote.

After finding no response at that address, the crew called Bedfordshire Fire and Rescue Service to force entry.

When no-one was found at the property, the case was closed.

The coroner said the East of England Ambulance Trust used a system supplied by Ordnance Survey, but that postal addresses and property coordinates were "not always accurate".

She added that although it would not be feasible for the database to be "100% accurate" due to new builds or property changes, Johnson had bought his home more than 11 years ago.

"He had been paying council tax since this time. It is therefore of concern why the database still did not have full details of his address," she said.

Whiting sent the report to Ordnance Survey, which has to respond to the report within 56 days.

An Ordnance Survey spokesperson said: "We are carrying out a review into the matters raised and will respond to the coroner in accordance with the prescribed process.

"We are unable to comment further at this time."

An East of England Ambulance Service spokesperson said: "Following this incident, we carried out a full investigation and reviewed our practices to strengthen the processes we use when an address cannot be located on the Ordnance Survey Map Database, ensuring the correct address and relevant information are added to our systems."

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