Ernest Roy Gray · Prevention of Future Deaths report

On 4th December 2023 I commenced an investigation into the death of Ernest Roy Gray 95. The investigation concluded at the end of the inquest on 4th November 2025. The conclusion of the inquest was that Ernest Gray died of natural causes with how when and where he came by his death being recorded that Ernest Gray was taken to hospital after he became unwell on 19th November 2023 and was diagnosed with ongoing delirium and intravascular dryness following a recent myocardial infarction on a background of heart failure, chronic kidney failure and hypertension. He died on 24th November 2023 at William Harvey hospital after developing pneumonia with a conclusion of Natural Causes

Ernest Gray lived with his partner of 30 years, it was a loving relationship. On 6th November 2023 Mr. Gray had been admitted to QEQM hospital after he suffered a myocardial infarction. On 8th November 2023 he presented as agitated & confused and was diagnosed with hyperactive delirium and heart failure Thereafter he was variously described as calm or agitated and aggressive at times, getting out of bed and wandering. He was irrational and demanding to be taken home. On 10th November 2023 a DOLs was put in place and remained for duration of stay. On 11th November 2023 he was aggressive, throwing things from a table and trying to hit staff. He refused all medications but was calm in the afternoon. His behaviour could be characterised as experiencing episodes of agitation followed by periods of calm when he became apologetic. Over the course of next few days he was medically optimised for discharge as his hyperactive delirium was resolving and there were no further incidents of aggression although he remained confused. He was discharged from hospital on 15th November 2023 to his family home.

There was little evidence about his condition after discharge, those that saw or spoke to him described his behaviour as unusual.

On 18th November 2023 Ernest Gray flagged down someone in the street asking for help. His partner was discovered deceased in the kitchen. It was later established that she had been subjected to a sustained attack ████████

Ernest Gray was arrested. After examination by a nurse he was declared to be fit to be detained and he was later interviewed during which he made some admissions, some statements which were contradictory within themselves and with other statements and some that were confused. Within three hours of the interview Ernest Gray became unwell and was taken to hospital where he was diagnosed with hyperactive delirium and heart failure. He remained under constant supervision of the police whilst being cared for in hospital and within 12 hours of admission attacked one of the police officers whilst being attended by a nurse; ████████ Mr. Gray died 4 days later.

(1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner. His daughter was consulted in the discharge process but the hospital did not attempt to contact his partner who was his carer.

(2) Although a number of persons from different disciplines were involved in planning Mr. Gray’s discharge, there was no evidence of a holistic approach being taken of the discharge or in communication of the patient’s ongoing needs following discharge

(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged