Matthew David James Simmonds · Prevention of Future Deaths report

On 17 August 2011 I commenced an investigation into the death of Matthew David James Simmonds, age 39. The investigation concluded at the end of the inquest on 14 March 2014. The conclusion of the inquest was that the deceased died due to Interrupted ventilation in a patient dependent on assisted ventilation due to Von Hippel-Lindau Syndrome and I recorded a narrative conclusion set out in Box 4 below.

1. Matthew Simmonds was suffering from Von Hippel-Lindau Syndrome, as a result of which he was quadriplegic and was fully dependent on invasive ventilation.

2. He was ventilated by a ventilator, which required changing every 24 hours, a procedure which operated satisfactorily whilst he remained in hospital.

3. A discharge care plan was put in place on 24 June 2011, by which time his condition had deteriorated to the extent that he had a short life expectancy, but he continued his wish to spend the remainder of his life at home.

4. The limited time before his discharge from hospital contributed to a condensed period for the planning of, and appropriate training for, his care package to be put in place by a provider in the community.

5. Matthew Simmonds was discharged from Southampton Hospital on 6 July 2011 and returned to his home at 68 Oakmount Road, Chandlers Ford, where he was cared for initially by a nurse who had no experience of working in an intensive care or high dependency unit in hospital. He was using the same ventilator provided by the hospital successfully during the day.

6. At approximately 20.00 hours a second nurse arrived at the house. She has intensive care training and experience. The handover was in progress and both nurses were present and assisted when the original ventilator was substituted.

7. At a time before 21.35 and likely to be about an hour earlier, during the change of ventilators, assisted ventilation to Matthew Simmonds ceased, as a result of the replacement ventilator not being switched to a functioning mode.

8. This fact was not observed until just before 21.35 when the ventilator was found to be in stand-by mode and he was seen to be deceased.

(1) Hampshire Primary Care Trust (then responsible for commissioning services) carried out a Serious Incident Review as a result of this death and have since put into effect an action plan for commissioning services in the case of complex care pathways for discharges to the community particularly in the case of ventilated patients.
(2) I heard evidence that Hampshire Clinical Commissioning Groups successors to the Primary Care Trust have adopted this plan and that it is working satisfactorily.
(3) The plan was prepared locally and has not been shared with CCG's outside the County. My concern is that to prevent deaths in other parts of the country all Clinical Commissioning Groups should adopt the plan.