Investigation and inquest
On the 30th April 2013 I commenced an investigation into the death of Wilfred Roy ASPINWALL, Aged 82. The investigation concluded at the end of the inquest on 24th June 2014. The conclusion of the inquest was
Ia Congestive Heart Failure
Ib Hypertensive Heart Disease
II Recurrent and Metastatic Lung Carcinoma
Wilfred Roy Aspinwall died of Natural Causes
Circumstances of the death
Wilfred Aspinwall was a prisoner at HMP Liverpool. He was a frail gentleman with several co-morbidities. Whilst in Prison was residing on the health care ward. He had sustained previous falls at prison and sustained a further fall on 7th/8th March 2013, fracturing his hip and was then transferred to University Hospital Aintree. Whilst in UHA, he has sustained further falls on Ward 35. He suffered a gradual deterioration of health and on Sunday 21st April 2013, Wilfred’s breathing became laboured at 0910hours and he sadly died. Medical history included Lung Cancer, with part of lung being removed in 1995, renal failure and worsening dementia. There was considerable confusion concerning the cause of death after both a consultant histopathologist and a consultant neuropathologist attributed fatal events to cerebral pathology caused by falls. The Court instructed a consultant neurosurgeon who met with the pathologists reviewed the clinical presentation including scans, where after all three doctors agreed that the death was due to natural causes.
Coroner’s concerns
At the inquest hearing it was clear that the PPO report and Clinical Review had not been sent to nor shared with the Healthcare provider at HMP Liverpool. It might be considered good practice for future reports, in all prison fatalities should to be sent to either the head of healthcare and/or the commissioning NHS Trust to ensure that recommendations have an optimal effect.