David Anthony Ince · Prevention of Future Deaths report

On 27 June 2014 I commenced an investigation into the death of David Anthony Ince. The investigation concluded at the end of the inquest on 23rd October 2014. The conclusion of the inquest was

medical cause of death

1(a) Hypoxic-ischaemic encephalopathy
1(b) Cardiac arrest (resuscitated)
1(c) Ischaemic heart disease

and narrative conclusion

David Anthony Ince was admitted by ambulance to Royal Preston Hospital at 00.06 on 26/06/14 having suffered a collapse at home. The clinical history and investigations suggested that he had been a syncopal episode of the sort Mr Ince had been suffering for some months. He was discharged in the early hours but shortly after having arrived home, he suffered a cardiac arrest which was unsurvivable despite readmission to hospital.

See narrative conclusion above.

(1) In the course of the Inquest hearing, it became apparent that the NWAS electronic record referred to an ECG having been carried out on Mr Ince by the ambulance staff at 11.35pm, prior to his first admission to A&E. However the fact of an ECG and its relevant features was not recorded in the notes of the A&E nurse who received the verbal handover from NWAS personnel on arrival at RPH, and no ECG trace was handed over or seen by A&E staff.

(2) It was the evidence of the Middle Grade doctor in Emergency Medicine, who had subsequently assessed and treated Mr Ince in the A&E department, that NWAS staff often have to be asked for ECG traces which they have obtained on patients, and will often have to return to their vehicles to get them, rather than handing them over to A&E staff as a matter of course when delivering patients to the department.