Brian Fredrick Mottram · Prevention of Future Deaths report

On 16th November 2020 I commenced an investigation into the death of Brian Mottram. The investigation concluded on the 26th May 2021 and the conclusion was one of;
Narrative: Died from Covid 19 pneumonitis not diagnosed until after his death contributed to by his previous necessary surgery for lung cancer caused by a combination of smoking and asbestos exposure during his working life.
The medical cause of death was 1a Covid 19 Pneumonitis; II Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease, Previous Right Upper Lobe Resection for Lung Adenocarcinoma, Type 2 Diabetes Mellitus.

On 15th November 2020, Brian Fredrick Mottram was found unresponsive at his home address, ████████ Markham Street, Hyde. He had been feeling unwell for over a week. On 13th November 2020 he had a telephone consultation with the GP. He reported shortness of breath, a cough, a tight chest, feeling hot and cold and not eating. He was not seen face to face and he was prescribed antibiotics. Post mortem examination found that he had died from Covid 19 pneumonitis. He was at risk of complications of Covid 19 due to his underlying health issues including diabetes, chronic obstructive pulmonary disease and a previous lobectomy for lung cancer. The lung cancer was due, on the balance of probabilities, to a combination of smoking and asbestos exposure during his working life.

1. The inquest heard that the GP surgery in common with surgeries across Tameside had a policy of predominantly using telephone appointments rather than face to face or video appointments. It was accepted at the inquest that Brian Mottram’s symptoms were consistent with Covid 19 but not there was no evidence before the Court that they were considered as such by the GP. A face to face appointment and testing in such a scenario may well have led to identification of Covid 19 and different treatment.
2. It was unclear during the inquest how GPs in Tameside were identifying high risk potential Covid 19 cases or the tools that they had to assist with identifying when to bring in for additional assessment patients who were particularly vulnerable to the effect of Covid 19 to check, for example oxygen levels consistent with silent hypoxia.