Alan Harry Hunter · Prevention of Future Deaths report

On 6th January 2021 I commenced an investigation into the death of Alan Harry Hunter. The investigation concluded on the 13th September 2021 and the conclusion was one of narrative. Died from frailty contributed to by rapid weight loss in hospital when his BMI was not correctly calculated and the relevant NICE guidance was not adhered to, exacerbated by repeated urinary tract infections.
The medical cause of death was 1a Frailty; II Covid-19, Urinary Tract Infection on a background of catheterisation

Alan Harry Hunter was admitted to Stepping Hill Hospital following a fall at Bramhall Manor. On admission he had a urinary tract infection and had periods of confusion and delirium. His BMI was not correctly calculated on admission and his MUST score was not correctly calculated. During his admission to Stepping Hill Hospital the NICE guidance on measuring weight was not followed. He lost 7kgs in weight taking his BMI to 15. He became increasingly frail. Whilst an inpatient he contracted Covid 19 on the balance of probabilities from another patient. At the time regular swabbing of patients was being undertaken but results were taking approximately 48 hours to be received by the hospital. Alan Hunter was discharged to Fernlea Care Home. His BMI was 15 and he was very frail and lethargic. He developed a further urinary tract infection. He continued to deteriorate and died at Fernlea Care Home on 30th December 2020.

The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.