Robert Andrew Power · Prevention of Future Deaths report

On the 22nd May 2017 I commenced an investigation into the death of Robert Andrew Power. The investigation concluded at the end of the inquest on the 4th May 2018. The conclusion of the inquest was natural causes. The medical cause of death was 1A Bronchopneumonia and urinary tract infection, 1B Multiple Sclerosis.

Robert Andrew Power “Robert” was a 49 year old man who lived in a care home specialising in neurological conditions. He had a history of significant drug and alcohol abuse. In 2007 he suffered a marked change in his physical abilities, and he underwent extensive investigations. He was diagnosed with gliomatosis cerebri, and discharged to a terminal care home. This diagnosis was incorrect. In 2014 his GP requested an assessment of Robert. Neurological opinion was sought, and it was determined that Robert had suffered significant damage to his brain, and had a chronic undefined inflammatory condition affecting his brain. In July 2015 Robert was admitted to a care home specialising in neurological management. Thereafter whilst Robert’s condition remained relatively stable, he was admitted to hospital on multiple occasions suffering with aspiration pneumonia, and / or seizure activity. Following ongoing deterioration, and after discussion with his family, it was agreed there would be no further escalation of treatment in the event of further deterioration. On the 12th April 2017 Robert was admitted to hospital suffering with aspiration pneumonia. He was discharged on the 4th May 2017 for palliative care. His condition steadily deteriorated. He was regularly reviewed by his GP. Robert passed away on the 17th May 2017.

Robert whilst being treated as a patient by the trust was essentially lost to follow up between 2007 – 2015. No explanation was given as to why this happened.

For the reasons given in my summary of evidence I determined that there was no evidence that this area of concern had any direct causative impact on Robert’s death. However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow up care. It is acknowledged that significant steps have already been made.