James Collier SIDDONS · Prevention of Future Deaths report

On 10 February 2022 I commenced an investigation into the death of James Collier SIDDONS, aged 91 years. The investigation concluded at the end of the inquest on 24 January 2025. The conclusion of the inquest was that Mr Siddons died on 31 January 2022 at University Hospital Lewisham, London (UHL). The medical cause of death was recorded as

1a Sepsis
1b Aspiration pneumonia and pyelonephritis
1c Ischaemic heart disease, osteoporosis, previous stroke, Alzheimer's disease

I concluded with the following narrative

Mr Siddons died in hospital from sepsis to which he had become increasingly vulnerable due to deteriorating life-limiting medical conditions. He had been admitted to hospital having sustained a fractured humerus whilst resident at a nursing home.

Mr Siddons had been admitted to UHL on 18 January 2022 having sustained a fracture of his left humerus at Sloane Nursing Home, Beckenham. The precise circumstances of the injury have not been established. Mr Siddons suffered from a significant number of co-morbidities including but not limited to Alzheimer's disease, osteoporosis, ischaemic heart disease and previous stroke resulting in very severe frailty. Mr Siddons made a good recovery from the facture and was waiting for a new nursing home placement when he developed raised inflammatory markers suggestive of infection. There was radiological evidence of aspiration pneumonia to which he was vulnerable due to dysphagia as a manifestation of late-stage Alzheimer's disease. He had also developed pyelonephritis. He died suddenly from sepsis, his condition having remained stable, despite appropriate treatment with antibiotics, on 31 January 2022.

Mills Family Ltd (Mills)

1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
2. Mills have a policy setting out a broad overview of the principles of investigation but no detailed guidance on how an investigation should be conducted within its organisation
3. There is no routine investigation training for managers

London Borough of Bromley (LBB)

4. Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly but had to be conducted without Mills being satisfied that all the relevant issues were known