Billy Longshaw · Prevention of Future Deaths report

On 5th May 2021, Alison Mutch OBE, Senior Coroner for Greater Manchester (South) opened an inquest into the death of Billy Longshaw who died on 7th March 2021 at Stepping Hill Hospital, Stockport aged 22 years.

The investigation concluded with an inquest which I heard on 21st February 2022.

The inquest concluded with a Narrative Conclusion to the effect that Mr Longshaw died as a consequence of complications of an undiagnosed sigmoid volvulus.

Billy Longshaw died at Stepping Hill Hospital, Stockport on 7th March 2021. Mr Longshaw had a complex medical history, including significant learning disabilities.

A post-mortem examination undertaken by Dr ████████, Consultant Histopathologist, determined that the medical cause of Mr Longshaw’s death was:

1) a) Acute bowel obstruction;
b) Ischaemic sigmoid volvulus.
2) Cardiomyopathy due to D2-Hydroxyglutaric aciduria.

Mr Longshaw had been taken to the Emergency Department of Great Western Hospital, Swindon, following experiencing sudden onset abdominal pain and an episode of vomiting on a car journey.

In the Department, Mr Longshaw was found to have mostly normal physiological observations, and his abdominal examination was considered to be normal by the junior hospital doctor who saw him.

Mr Longshaw was permitted to leave the Department without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded.

On the balance of probabilities, the sigmoid volvulus which led to Mr Longshaw’s death was present (albeit at an early stage) when he was assessed in Swindon.

To the Chief Executive, Great Western Hospitals NHS Foundation Trust

1) Notwithstanding Mr Longshaw died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him.

Prompt, rigorous and effective investigations into serious clinical incidents are essential to deriving learning and improving patient safety;

2) The ’48 Hour Report for Significant incidents resulting in Moderate Harm and above’ prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust’s own medical records), prefaced as it is by the assumption that ‘the patient self-discharged against medical advice’. The Trust’s (limited) review of this matter represents a missed opportunity to consider vital issues such as the presentation of patients with significant learning disabilities to the Emergency Department, and the practical application of the Mental Capacity Act 2005 in this clinical setting.

To the Chief Executive and Registrar, The General Medical Council

3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005, and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings, and accompanying guidance such as that produced by the General Medical Council in this regard.