Mr Taylor · Prevention of Future Deaths report

In August 2018 an inquest was opened into the death of Mr Taylor who died on 31 July 2018. The inquest concluded at a hearing on 31 October 2018 where it was found that Mr Taylor had died as the result of an accident. The cause of death given at inquest was:
1a)Sepsis;
1b) chest infection;
1c) head injury
1h) chronic obstructive pulmonary disease

On 27 July 2018 Mr Taylor suffered a fall at his home address and struck his head. He was taken to the Alexandra Hospital where a CT of his head revealed a large acute haematoma. After management of his condition and a further CT scan he was transferred to your Trust in the early hours of 28 July 2018.

Following his admission it was noted that Mr Taylor displayed signs of agitation and tremors/seizures. It was felt that this was likely to be related to alcohol withdrawal. The doctor reviewed the Trust's protocol the management of such patients and, in error, prescribed and administered Diazepam.

On 29 July 2018 Mr Taylor suffered a respiratory arrest. He was given an antagonist and recovered promptly to his pre-arrest condition. Sadly, Mr Taylor developed a chest infection and, despite treatment, subsequently deteriorated and died in the Trust on 31 July. One of the matters investigated at the inquest was whether, as a consequence of the respiratory arrest, Mr Taylor had aspirated. As a matter of fact it was found that the aspiration had occurred at the time of the original fall.

(1) I heard in evidence from Mr Young, the Trust's Clinical Director who had carried out a Root Cause Analysis. I heard also from ████████ one of the Trust's consultant neurosurgeons. Both consultants expressed their belief that neurosurgical patients of this nature required additional support from their consultant physician colleagues. I was told that this has been an issue for some time and remained unresolved. In particular, there was concern that a junior neurosurgical doctor was left to implement an alcohol withdrawal regimen. I was told that these difficulties are not confined to patients who are admitted with alcohol-related issues but extend across the whole range of neurosurgical patients who require medical input.

(2) I was told that the alcohol withdrawal protocol was difficult to understand. This resulted in the doctor prescribing diazepam when Lorazepam should have been used. I was told and shown an action plan that the Trust intends to implement to improve the process.

(3)