Andrew John Nickolls · Prevention of Future Deaths report

On the 15th October 2013 I commenced an Inquest into the death of Andrew John Nickolls. The Inquest concluded on the 10th June 2015.

The medical cause of death was found to be:

1a Unascertained

The conclusion of the Inquest was “Open”.

The deceased was discharged from Torbay Hospital on the 12th September 2013. When a cause for concern was raised he was found by Police Officers in his flat.

The pertinent circumstances of Andrew’s death were that he was living in Dartmouth. He was registered with a GP in Plymouth. He attended Torbay Hospital on numerous occasions.

Following his death the Torbay & South Devon Clinical Commissioning Group conducted an investigation into the circumstances of his death. This investigation was carried out by ████████. A copy of her report with substantial recommendations has been shared with the NEW Clinical Commissioning Group and the Torbay & South Devon Clinical Commissioning Group. I also understand copies are to be shared with the Chief Executive of: Plymouth City Council, Devon County Council and Torbay Council.

The principal learning point is to be that there is an advantage in a patient being looked after by a primary carer (i.e. a GP) within the Clinical Commissioning Group. If this is not the case, then it is imperative that there is clear information sharing, particularly where there is a vulnerable adult and there is a possibility they are neglecting themselves.

May I observe there may be an advantage in sharing information with Devon & Cornwall Police who clearly keep an index of vulnerable individuals as these individuals may come to the Forces notice through other routes.