Hubert Kelly · Prevention of Future Deaths report

On the 21st March 2018, I commenced an investigation into the death Hubert Kelly. The investigation concluded at the end of the inquest on 12 September 2018. The conclusion of the inquest was a short narrative conclusion of natural causes death.

The cause of death was:

1a Old Age
2 Hypertension, Aortic Stenosis, Bullous Pemphigoid

i) On the evening of 13th November 2017 Hubert Kelly was taken to hospital in an ambulance following a deterioration in his health;

ii) He was triaged by a nurse at the Accident and Emergency Department at Russells Hall Hospital;

iii) He was directed to the waiting area of the emergency department where he spent four hours in a wheelchair sat with his family;

iv) There was no meaningful interaction with Mr Kelly during those hours with nursing staff until it was noticed that he was not disrupted by noise in the waiting room. Nursing staff conducted a check at 4am and discovered that Mr Kelly had passed away.

1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;

2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;

3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.