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Investigation and inquest
On 22/11/2023 this Court commenced an investigation into the death of Omar Abdi Ahmed aged 54 years. The investigation concluded at the end of the inquest on 15th July 2024. The Court returned a narrative conclusion;
“Omar Abdi Ahmed died on 20th November 2023 in hospital due to hypothermia. Mr Ahmed, an amputee who received domiciliary care three times a day, was found by carers, unresponsive at home on 15th November 2023. Mr Ahmed had developed pneumonia which, along with ischaemic heart disease had contributed to his hypothermia. Mr Ahmed had chosen not to activate his home's heating system.
Mr Ahmed’s medical cause of death was determined as;
1a Hypothermia
1b Pneumonia and Ischaemic Heart Disease
II Diabetes Mellitus Type II
Circumstances of the death
Omar Abdi Ahmed was a 54-year-old man who lived alone in a flat in Forest Gate. Mr Ahmed had significant comorbidity and had undergone a surgical amputation of one leg and the partial amputation of the other.
Mr Ahmed received district nursing care to monitor and treat his wounds.
Mr Ahmed had a package of domiciliary care, commissioned by the local authority to assist him in undertaking the tasks of daily living such as cleaning, personal hygiene, preparing meals and mobilising. The care was contracted to a private provider who undertook three visits per day, a provision that was topped up with an extra 3 hours per week to assist Mr Ahmed with cleaning and community engagement.
Mr Ahmed was admitted to hospital by ambulance on 15th November.
On the third domiciliary care visit of the day on the evening of 15th November 2023, Mr Ahmed was found to be unresponsive.
The ambulance service found Mr Ahmed hypothermic (28c) with reduced consciousness lying in a foetal position in bed. The patient was assessed to be in septic shock and was noted to have recently developed a pressure ulcer.
A safeguarding report was made regarding the condition of the deceased who was found to be wearing a soiled incontinence pad. His right leg was dressed in a dirty bandage that had not been changed for two weeks. The flat was unheated and unsanitary.
After transfer to hospital diagnoses of sepsis and hypothermia were confirmed, despite treatment Mr Ahmed died at 2059 on 20th November 2023.
Coroner’s concerns
1. Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health.
2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment.
3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
Information checked against the published report and official responses