ALLAN WILLIAM CUNLIFFE · Prevention of Future Deaths report

On 19th July 2018 an investigation was commenced into the death of ALLAN WILLIAM CUNLIFFE (dob 13th August 1941). The investigation concluded at the end of the inquest on 10th October 2019.

The narrative conclusion of the jury at inquest was:
“Insufficient record keeping and communication probably led to an avoidable death”

The medical cause of death was
1 a) Sepsis
1 b) Perforated bowel
1 c) Bowel perforation due to adhesions

(1) Allan Cunliffe (AC) had a history of bowel problems and mental health issues. On 30th March 2018 he was admitted to Summers Ward (part of Pennine Care NHS FT) under the MHA with psychotic symptoms. Towards the end of May consideration was being given to discharge.
(2) On 7th June AC was felt to be constipated and was admitted to Tameside Hospital for 10 days. Sigmoid volvulus was diagnosed and treated. AC was discharged to Summers Ward, with a 6 week outpatient appointment.
(3) The jury made the following findings of fact (box 3):
“Allan Cunliffe became ill on 17th July 2018 in Summers Ward. Inadequate actions followed which contributed to a delay in presenting to A&E. Failure include: inadequate communication between nursing and medical staff; a lack and/or incomplete calculations of NEWS scores; a failure to adhere to the NEWS protocol, especially re further regular observations. These failures were probably causative to Allan Cunliffe’s death, in that surgery prior to 22.30 probably would have resulted in his survival
Further failures that were not causative include: the ruling out of bowel obstruction on the afternoon of 17th July 2018; a delay in starting oxygen at 02.00 on 18th July 2018; the request for an ambulance ‘within an hour’ rather than Category 1 urgent at 02.30”.
(4) AC was transferred to Tameside Hospital, arriving at 04.09. He was resuscitated and sigmoid volvulus was diagnosed and treated with a sigmoidoscopy - in fact, a review of the x-rays suggest that this was wrong and showed free air indicating perforated bowel.
(5) AC deteriorated. He died in A&E at 07.03 on 18th July 2018.

(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training.