PARAMEDICS were not negligent in their care of a Powys man despite "chaotic" attempts to resuscitate him, a coroner has found.

Gordon Smith died in Cardiff in March 2019 after suffering a heart attack. He was in the city working for the Welsh Government.

His family had raised concerns at an earlier inquest hearing in October, this year, that the 45-year-old was let down by "gross failures" in his care by Welsh Ambulance Service paramedics and that he had died of a "failure of leadership".

But at the inquest conclusion in Pontypridd Coroner's Court today (Wednesday, November 27), assistant coroner Gaynor Kynaston said due to the underlying condition of his heart "on the balance of probabilities" she could not say that Mr Smith would have survived if he had had "the best care".

READ MORE: Powys man who died in Cardiff left without defibrillator shock for six minutes

She agreed that an intubation tube had likely been placed in Mr Smith's oesophagus instead of his airway, and a machine that would have told paramedics to shock him with a defibrillator had not been switched on for eight minutes.

She also described the resuscitation process as "chaotic", saying: "No-one took the lead or co-ordinated the resuscitation process.

"No-one could give a reason why the machine was not switched on."

Mr Smith was later reintubated correctly by another ambulance team and was shocked two times on his way to University Hospital of Wales in Cardiff, but he died a short time after he arrived.

The hearing in October heard from Dr Navroz Masani, a consultant cardiologist at the University Hospital of Wales, who said that even with optimal care Mr Smith's chances of survival would only have been 30 per cent.

This was due to his main artery being narrowed by 90 per cent in two places, and his two other arteries being narrowed by 50 per cent. He added that it was most likely a blood clot that led to him suffering a heart attack 12 to 24 hours before his collapse.

Ms Kynaston said the evidence heard in October had been "extremely complex" and had led to a delay in her giving a decision.

But she added that although Mr Smith had been intubated incorrectly and the monitoring machine had not been turned on by the first paramedic team, she could not say that the Welsh Ambulance Service Trust (WAST) had been "negligent".

She said: "I cannot add negligence to this conclusion because I cannot establish a link between the care by WAST and Gordon's death.

"I cannot say he would have survived."

What happens at an inquest and what can the press report?

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Here we will try and answer some of your questions about what will happen, what can be reported and why.

Ms Kynaston also confirmed she would not be making a Regulation 28 report to prevent future deaths after hearing evidence from WAST of changes that have been made since Mr Smith died.

These include having two people intubate a patient and the use of "pit stop CPR" which is designed to bring structure to how paramedics treat patients in cardiac arrest.

She concluded by apologising to Mr Smith's family for the delay in holding the inquest after the incident was not reported by the ambulance service for 10 months and only came to light after relatives made a Freedom of Information request.