KEWAR GUY DOMINIC HARDING · Prevention of Future Deaths report

On the 9th April 2013 the coroner for Birmingham commenced an investigation into the death of KEWAR GUY DOMINIC HARDING aged 27 at Queen Elizabeth Hospital. Jurisdiction was passed to me on the 18th June 2013 and the investigation concluded at the end of an inquest held at Dorchester on the 15th August 2013.. The conclusion of the inquest was that he had died of natural causes with the medical cause of death being (a) Multiple organ failure, (b) Dilated cardiomyopathy, (c) Sepsis (treated) (i) Obesity Type III Diabetes Mellitus, Diverticulitis and Infected Cellulitis.

Mr Harding had a learning disability and lived at home with his mother. He was seen by ████████ GP on the 12th and 19th March 2013. On the second occasion he did not exhibit signs of serious physical illness but ████████ felt that a mental health assessment should be carried out urgently. She telephoned ████████ to discuss her concerns and to request an urgent referral and followed this up with a letter dated 20 March 2013. ████████ advised ████████ that an assessment would be carried out in days. It would appear that Mr Harding deteriorated over the Easter weekend and ████████ called The Bridges Medical Centre on Tuesday 2nd April to express her concern about her son. ████████ visited the family home that day to find Mr Harding hypoxic, hypotensive and oedematous with suspected sepsis. Mr Harding was admitted to Dorset County Hospital critically unwell and was later transferred to Birmingham on the 6th April for consideration of extra-corporeal assistance and possible heart transplantation but he sadly died on the 7th April.

That an urgent mental health assessment was requested on the 19th March 2013 which had not taken place before the 2nd April 2013. If a health professional had visited the family they may have detected a decline in his physical health at a stage where active treatment could be commenced which may have prevented his death.