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Investigation and inquest
On 30th November 2016 an investigation commenced into the death of David Lee BIRTWISTLE, Aged 44. The investigation concluded at the end of the inquest on 23rd March 2017.
The conclusion was that the medical cause of death was
(I)(a) Pulmonary embolism; (I)(b) Deep vein thrombosis and cardiomyopathy
The conclusion as to the death was a narrative conclusion which read:
Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death. This meant that further tests, which could have led to an earlier diagnosis of his condition, were not done.
Circumstances of the death
Mr. Birtwistle died of a pulmonary embolism having been diverted from an accident and emergency assessment two days prior to his death. This meant that further tests, which could have led to an earlier diagnosis of his condition, were not done.
No 111 referral information was available to “front door” or the ED.
Coroner’s concerns
1. A national review of serious incidents and near misses in similar “front door” services should happen as a matter of some urgency in order to identify common themes that can inform future service design.
2. NHS 111 should share information with ED departments immediately. This needs to be in a user friendly format.
Information checked against the published report and official responses