Gordon Eric Atkinson · Prevention of Future Deaths report

On 18/02/2015 I commenced an investigation into the death of Gordon Eric Atkinson, 80. The investigation concluded at the end of the inquest on 07 August 2015. The conclusion of the inquest was NATURAL CAUSES AGGRAVATED BY SELF-NEGLECT. The deceased died in Derriford Hospital, Plymouth on 6 February 2015. He had an unwitnessed fall against an oil filled fire towards the end of 2014 which resulted in burns. He had numerous falls, he had mental capacity, he neglected himself in his own accommodation. His medical cause of death was 1 (a) Bronchopneumonia and Coronary Artery Disease II Infection Chest and Leg Wounds

The deceased was divorced gentleman who lived alone in a Caravan at 19 Valley Walk, Glenholt, Plymouth. He had lived there since the 1970’s following a divorce. The caravan was in poor condition, damp and had no running hot water. The deceased spent the majority of his time in his living room where he slept and ate mainly in his chair. He had twice weekly visits from the District Nurse Team. It appears that South Western Ambulance Service called on seven occasions at his address following falls. On 9 January he was admitted to a Care Home and then to a Nursing Home. He was admitted to Hospital where a safeguarding concern was raised. The matter was investigated by ████████ of Devon and Cornwall Police Public Protection Unit. She will be making a Report to Plymouth Adult Safeguarding Board.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The deceased appeared to be living in accommodation that was unsuitable.
(2) On the evidence it was clear that the deceased was neglecting himself. In particular, his sister pointed out that his bed was soiled with faeces and remained unchanged.
(3) It appeared from the evidence at the Inquest that his care package was inappropriate