Keith Thomas Graham · Prevention of Future Deaths report

On the 30th May 2012 I commenced an investigation into the death of Keith Thomas Graham aged 45 years. The investigation concluded at the end of the inquest on the 29th November 2013. Cause of death – Multiple Injuries. On the 22nd May 2012 the deceased left a public house in Burgh by Sands on his motor cycle having consumed three pints of beer. He travelled along the A595 road at high speed when he was in collision with a bullock. He was transported to the Cumberland Infirmary, Carlisle where he underwent surgery, dying from his injuries on the 28th May. The conclusion of the inquest was Road Traffic Collision.

The deceased was involved in a Road Traffic Collision. He reached the Cumberland Infirmary, Carlisle at 20.00 hours. He was in a poor condition. It was planned that he be taken to a CT Scanner which occurred at 21.20 hours. He was suffering from Hypotension and was taken to Theatre at 21.30 hours. The on call Consultant was not contacted until 21.15 hours. A chest drain was misplaced and caused damage to the liver. He underwent a Thoracotomy and three Laparotomies in the space of some 5 ½ hours. The consensus of medical evidence was that on the balance of probabilities he would have died of his injuries in any event.

To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre.