Dimitar SHTYANOV · Prevention of Future Deaths report

On 20th August 2012 I commenced an investigation into the death of Dimitar SHTYANOV, born on 18th August 1984. The investigation concluded at the end of the inquest on 26th July 2013. The conclusion of the inquest was that the medical cause of death was 1a Bilateral Pneumothoraces due to 1b Acute Asthma and that this was an Accident.

Dimitar was a Bulgarian seasonal Agricultural worker with a long history of asthma treated with bronchodilator inhalers, theophylline and long acting injected corticosteroids in Bulgaria. He did not declare this history when he completed pre-employment questionnaires. He arrived in Lincolnshire for his second year of seasonal work on 6th July 2012. He became ill in early August and attended the A&E department at Pilgrim Hospital 9th & 10th August 2012. Clinical staff at the hospital did not learn of his history of Asthma. He was treated for a wheezy chest infection with antibiotics and a salbutamol inhaler. On the 11th of August, his condition deteriorated and his fellow workers brought him to the A&E department at Pilgrim Hospital. He was in cardiac arrest on his arrival and resuscitation attempts were unsuccessful

(1) Evidence was presented to the effect that the majority of seasonal agricultural workers do not know how to access General Practitioner Services and indeed are not aware of the service. They often access primary health care at need via the accident and emergency department
(2) They are often not aware of either the 999 service or the 111 service
(3) They are often not aware that they are entitled to GP services in the UK, without charge, for the management of chronic medical conditions
(4) Dimitar obtained salbutamol inhalers (labelled in both English and Bulgarian – the latter in Cyrillic Script) and injectable long acting beclomethasone (labelled in Cyrillic script) by post from Bulgaria, with extra supplies being posted to him when he became ill. The evidence as to whether or not these medicines were shown to A&E staff was inconsistent. I was informed in Court that it is very common for seasonal workers with chronic conditions to have what would be prescription only medicines in the UK posted to them from home where such medicines can often be purchased freely without prescription.