Mr YZ · Prevention of Future Deaths report

On 23 April 2024 I commenced an investigation into the death of Mr YZ, aged 64. He had died on 2 March 2024 in his own home (sheltered accommodation).

The investigation concluded at the end of the inquest on 10 February 2025.

The conclusion of the inquest was a short narrative of ‘accident, with a contribution from natural causes’.

The medical cause of his death was

I(a) Hypovolaemic Shock

(b) Compound Fracture Dislocation of right Tibiotalar (Ankle) Joint

(c)

(d)

II Fatty Liver Disease, Huntington's Disease

(1) YZ was diagnosed with Huntington’s Disease in 2019.

(2) He died in his own home on 2 March 2024, in the early hours of the morning from extensive blood loss from a traumatic open fracture of the right ankle.

(3) He had an emergency careline cord in his home, managed by Appello, which he had activated at 0220 on 2 March. When the operator answered him YZ had spoken initially unintelligibly, and then in response to questions indicated he was ok and did not need help.

(4) The call duration was brief. It was logged as an accidental call.

(5) YZ did not receive medical assistance and died some time before 0800 the same morning, 2 March 2024.

(6) YZ’s failure to obtain prompt medical assistance contributed more than minimally to his death.

(1) YZ’s presentation with Huntington’s Disease involved altered pain pathways/responses, slurred speech, lack of or reduced insight, tendency to apathy and self-neglect and impaired cognitive processing.

(2) These are aspects of presentation that may be present in a wider group of other end-users of careline services (for example those with dementia) and are not limited to end-users with Huntington’s Disease.

(3) I found there was a missed opportunity to obtain life-saving medical assistance that was attributable to YZ’s impairments arising from Huntington’s Disease.

(4) YZ had called for assistance but the operator failed to identify that he had a major injury with significant blood loss.

(5) The interaction was very brief, YZ contributing only a few words, and I found key information might have been elicited if YZ had been given more time, asked to repeat his unintelligible opening words, or had been asked open and/or more specific closed questions.

(6) I found the operator who answered the call was trained and had followed the protocols that were in place for him at that time. He was not a clinician. His management of the call was in line with the guidelines applicable to his work (Appello Careline Limited guidelines, and the guidelines of the Telecare Services Association, which are followed by most of the careline services industry).

(7) After YZ’s death Appello Careline Limited quickly and proactively reviewed their procedures and amended their call protocols. At inquest they accepted the offer of the Huntington’s Disease Association to work with them to identify questioning methods or protocols that might further reduce the risk of similar outcomes in future.

(8) The Telecare Services Association was not a recognised interested person in YZ’s inquest.

(9) I am bringing a risk formally to their attention with this report. The risk is to careline users with similar presentations as YZ if the Telecare Services Association’s guidelines continue unamended.