Mark Anthony McKessy · Prevention of Future Deaths report

On 24th February 2023 I commenced an investigation into the death of Mark Anthony McKessy. The investigation concluded on the 11th July 2023 and the conclusion was one of Narrative: Died from the complications of decompensated alcoholic liver disease when agencies had not effectively shared information or recognised his needs until shortly before his death. The medical cause of death was 1a) Multi-Organ Failure; 1b) Pneumonia on a background of Decompensated Alcoholic Liver Disease; and II) Malnutrition.

Mark Anthony McKessy had learning disabilities and care needs. He lived in the community. His regular and prolonged use of alcohol led to him developing alcoholic liver disease. He had limited capacity to understand the risks that this presented to him due to his learning disabilities. The significant threat his lifestyle and health issues posed to his life was not recognised by agencies. There was limited information sharing by agencies and no understanding of how his learning disability was impacting his health. As a consequence his health continued to deteriorate. He was admitted to Stepping Hill Hospital and was diagnosed with decompensated alcoholic liver disease. He deteriorated and died at Stepping Hill Hospital on 18th February 2023.

The inquest heard evidence that he had significant leaning difficulties and his capacity was limited. He was known to agencies. Despite this the inquest heard evidence that steps to reduce the risks were not taken due to:

1. Poor communication/information sharing between agencies which meant that there was no coordination of care and no clear overview of his needs; and

2. A lack of recognition by agencies involved with him of his health issues and their inter relationship with his social care and learning disability needs including the extent to which he had capacity. This was compounded by limited Care Act assessments