Mr Adrian Ashford · Prevention of Future Deaths report

I opened an inquest into the death of Mr Adrian Ashford, who died on 15th December 2018 in Queen Elizabeth Hospital, Woolwich (043452-18 JB). An inquest was opened on 7th June 2019 and was concluded on 7th January 2020. The medical cause of death was: 1a Upper gastro-intestinal bleeding 1b Chronic Peptic Ulcer. The conclusion was Natural Causes.

Mr Ashford suffered from psychotic depression with associated anorexia, weight loss and constipation, about which he was fixated. This was sufficiently severe to have a colonoscopy which was normal and to require admission to a mental health ward. On 11th December he was transferred to A&E with concern about the risk of a GI bleed. He was transferred back as he was stable, without referral to a gastroenterologist. He was admitted to a medical ward the following day, but the risk of bleeding on initial assessment that day was not communicated to the consultant reviewing him on 12th. He was rehydrated and his further drop in haemoglobin ascribed to dilution. His circulation was restored with fluids the following day when the haemoglobin and blood pressure further dropped. He died after a massive GI bleed at 15.52 on 15th, from which he could not be resuscitated. Even if the diagnosis of his asymptomatic chronic peptic ulcer had been made by endoscopy before death, it cannot be concluded it would have enabled his life to be saved.

The family have made a submission listing eleven concerns, which they say trigger my Regulation 28 duty. These have been carefully considered. Three general remarks are needed; Firstly, individual matters of clinical misjudgment, still less retrospective missed opportunities do not in themselves trigger my statutory duty. Secondly that Mr Ashford’s death and the hearing of this inquest has raised awareness of risks and led to professionals reviewing their clinical practice. Thirdly service developments have addressed some risks such as the urgent cancer referral process and the unified connect care system, linking health care across organizations, which is being implemented.

The court has received submissions from QEH, that a PFD report is not required..

1. ████████ GP and ████████ Divisional Medical Director, both gave evidence of the value of having some system for regular weighing, and that it might save lives. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights.

2. The consultant in acute medicine, who was on call when Mr Ashford was admitted to A&E on 11th December 2018 by psychiatrists, concerned about the risk of GI bleeding, diagnosed constipation and returned him to a psychiatric bed. It appears he failed to identify the risks of GI bleed identified in A&E on 11th, nor the reasons for concern for urgent transfer (dehydration and drop in haemoglobin from 126 to 102g/l). On 14th he also failed to consider referral to a gastro-enterologist, after his blood pressure fell to 83/59 with a tachycardia of 112. He told the court “he was not thinking GI bleed”. Asked about learning from this death, he said that there was no change in his practice, other than increased awareness.