Dr Richard George Hardman · Prevention of Future Deaths report

On 10th August 2023, an investigation was commenced into the death of Dr Richard George Hardman, aged 77 years. The investigation concluded at the end of the inquest on 20th March 2024. The conclusion of the inquest was that the medical cause of death was:

1a) Aspiration Pneumonia
1b) PEG feeding
1c) Oropharyngeal Dysphagia due to Bulbar Myopathy due to radiotherapy for Tonsillar Cancer (2001) and Parkinson’s disease

The conclusion as to his death was that he died from aspiration pneumonia which arose as a result of a combination of natural disease and recognised effects of necessary medical treatment.

Dr Hardman underwent radiotherapy in 2001 for tonsillar cancer and after a number of years developed dysphagia which was later found to be a late onset side effect of the cancer treatment.

He was at risk of aspiration due to hypersalivation and mucus secretions, such that a PEG tube was inserted in July 2022 to mitigate the risk. He developed symptoms of and was diagnosed with Parkinson’s disease by a consultant neurologist. Parkinson’s disease further compromised his ability to swallow and breathe.

By May 2023, his respiratory system was significantly compromised, he was under the care and supervision of the North West Ventilation Unit (NWVU).

There were difficulties in identifying both the provider of a suction machine and training in the use of a suction machine at home, as he did not live within the immediate geographical area of the NWVU from which the recommendation for a suction machine came with the result that the machine was unavailable for a period of about a month. Dr Hardman then suffered a spontaneous sigmoid volvulus which was resolved as an in-patient, but without surgical intervention.

On 7th August 2023, Dr Hardman became unwell and on admission to hospital, was found to have aspiration pneumonia and a partial sigmoid volvulus confirmed at post-mortem examination revealed evidence of chronic aspiration.

There were a number of different medical disciplines involved in Dr Hardman’s treatment and care across a number of different NHS hospitals, but the absence of any lead practitioner meant that there was no global oversight of the various complex interacting conditions and care whilst the inquest did not find evidence to say, had such a lead practitioner been in place, that Dr Hardman’s life would have been prolonged or saved, the potential for more collaborated, holistic care was clearly apparent which could in patients with complex multi-disciplinary needs, prevent death.

The absence of any obvious mechanism for the various medical disciplines across different hospital sites to be brought together in complex medical cases under the leadership of a single practitioner in a position to evaluate and co-ordinate the best approach and combination of medical care for the patient.