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Investigation and inquest
On the 9th of May 2013 I commenced an investigation into the death of Timothy Peter Cowen (DOB 6.9.61, DOD 2.5.13). The investigation concluded at the end of the inquest on the 30th of September 2014 and I recorded a narrative conclusion in the following terms –
On the 23rd April 2013 Timothy Peter Cowen underwent an operation at the Maelor Hospital, Wrexham having previously undergone a substantial pre-operative assessment which took into account his severe learning disabilities and significant mobility limitations. The operation itself was uneventful and post operatively he was returned to the ward for ongoing care. He received nutrition by way of a peg feed and his feeding regime had been established over a long period of time such that he would receive nutrition in two daily sessions whilst upright. Post operatively this regime was changed in accordance with recognised dietary practices and he then received a single reduced dose of feed over a longer period whilst being propped up in bed. It is probable that during this period as a result of his existing medical conditions he aspirated resulting in infection. He was assessed as being fit for discharge on the morning of the 25th April 2013, although his actual discharge did not take place until that same evening at which point his carers who knew him best were concerned that his condition may have deteriorated rendering him unfit for discharge. Such concerns were not brought to the attention of nursing or medical staff at that time. Over the course of the next three days his condition continued to deteriorate resulting in his re-admission to the Maelor Hospital on the 28th April 2014. Despite surgical investigation and ongoing support he passed away on the 2nd May 2013 at 21.25 hours on ITU. as a result of Bilateral Extensive Pneumonia with features of Aspiration.
Circumstances of the death
The Circumstances of the death are outlined the above narrative conclusion.
The published report provides this section by reference to another part of the report.
Coroner’s concerns
1. That although a Root Cause Analysis undertaken by the health board has resulted in new training bundles being produced, training is not mandatory for all staff who would require to be made aware of the new procedures and protocols.
2. That whilst there has been established a new role of Acute Liaison Nurse to provide cohesion to the care given to patients requiring additional support, there are only three such ALNs and there is no cover in place when they are absent through illness or holidays.