Ruth Thompson · Prevention of Future Deaths report

On the 2nd of June 2017 an investigation into the death of Ruth Thompson, aged 60 years was commenced. The investigation concluded at the inquest on the 6th October 2017.

The medical cause of death was:
1a Dissecting Aortic Aneurysm and its treatment

There was a narrative conclusion that Ruth Thompson died as a consequence of naturally occurring disease exacerbated by recognised complications of necessary surgical intervention and the effects of prolonged immobility.

The deceased had a history of a cerebrovascular accident in 2006. On the 14th April 2017, whilst on holiday in Italy she became unwell and was admitted to Ospedale Monaldi, Naples having suffered a dissecting aortic aneurysm. Her condition was actively treated with surgical intervention in the form of grafting an aortic valve and aortic root and aortic? The surgical procedure was completed but complicated by her recovery. The recovery was further impaired by her then sustaining a pontine brain infarction and she underwent percutaneous gastrostomy and required movement. Following prolonged hospitalisation and conservative management of her condition, the deceased was diagnosed as having developed a breakdown and pressure sores whilst in hospital in Italy by reason of prolonged immobility. Despite ongoing active treatment, a care plan was developed to improve the condition of the deceased was noted to deteriorate around the 25th May 2017 and by the 30th May 2017 she was recognised to be entering end of life phase, receiving palliative medication until her death on the 31st May 2017.

1. Whilst the family and next of kin accepted that medical discharge from the Ospedale Monaldi and a decision for transfer was made on an assumption that the deceased was medically fit for transfer, the evidence revealed that:-
a. In fact, the deceased died within 16 days of repatriation having survived for over a month in hospital in Italy.
b. The assurances that the transfer team could speak English and communicate with the deceased at times, the deceased was accompanied by a German clinician with limited English communication and inadequate transfer notes in fact the United Kingdom.
c. No proper or informed consent was obtained for the transfer as the evidence suggested that very little information as to the condition and care plan of the deceased had been communicated to the deceased.

2. On her transfer to the United Kingdom, clinicians within the Accident & Emergency Department at the Royal Bolton Hospital were only supplied with two sheets of information from the hospital, written in Italian, which required doctors to use Google Translate, written attempt to interpret that document. The documentation was inadequate and not fit for purpose in that it failed to note or provide basic handover information including:-
a. Operative details;
b. Interventional treatment and observations;
c. Ongoing prescribed medication;
d. Recent test results;
e. Identification of investigative procedures and their results;
f. Treatment plan following discharge;

3. Accordingly, the issue of adequacy of communication of vital information to the deceased, her next of kin and treating clinicians in the United Kingdom following air ambulance transfer from abroad created delay and uncertainty in treatment and care.