Alan Walker · Prevention of Future Deaths report

On the 24th of January 2014 I commenced an investigation into the death of Alan Walker (DOB 11.08.32, DOD 23.01.14). The investigation concluded at the end of the inquest on the 11th December 2015 and I recorded a conclusion of Accidental Death

(a) The Circumstances of the death are that on the 22nd of January 2014 a nasogastric feeding set was connected to the IV line of the deceased, which resulted in the intravenous infusion of liquid feed as a consequence of which he died the following day due to 1(a) Toxic Shock.

(b) During the afternoon of the 22nd the NG tube had become detached from the feeding set on two occasions in quick succession and had thereafter been taped together, however these events were not recorded in the nursing notes and therefore other staff were not made aware that there may be a connectivity issue with this equipment during handover. Furthermore, staff handovers may not in any event be conducted by way of reference to the nursing notes.

That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time.