Jack Basil Lynn · Prevention of Future Deaths report

On 17th October 2013 I commenced an investigation into the death of Jack Basil Lynn, age 86 years. The investigation concluded at the end of the inquest on 14th February 2014. The conclusion of the inquest was that Jack Basil Lynn died from natural causes, the medical cause of death being:-

1a Haemopericardium
1b Ruptured Acute Myocardial Infarction
1c Coronary Artery Thrombus

Jack Basil Lynn lived alone at his home address. Staff from care providers Nightingales Home Help Service attended Mr Lynn on a daily basis morning and night, to ensure he was prompted to take his medication and to check on his well being. A carer who visited Mr Lynn on the 15th October 2013 for a planned 15 minute visit entered the house with a key. The carer observed that Mr Lynn was not downstairs when she called and assumed that he must have gone back to bed. She believed that Mr Lynn had taken his medication for that morning by looking at a plate on a table where he normally put that morning’s tablet, but it was probable in the circumstances that he had not taken his medication on that day. No further checks on Mr Lynn were made by the carer at that time to ensure his well being before she closed the door and left the property. Later that evening the same carer returned to the property and as Mr Lynn was still not downstairs she went upstairs to check on him. Mr Lynn was found unresponsive on the bathroom floor. Paramedics were called but could not assist and Mr Lynn’s death was pronounced at 20.03 hours.

Arrangements put in place for daily prompting with medication did not include keeping a medication communication sheet at Mr Lynn’s home address as a continuous record of his medications. This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly.

The absence of any check on Mr Lynn’s safety or well being during the allocated 15 minute visit on the morning of 15th October 2013 exposed Mr Lynn to potential risk, albeit that the sudden cardiac event which occurred could not have been prevented. The risk was present, nonetheless, and creates a risk that future deaths might occur if action is not taken.