George Foster Thompson · Prevention of Future Deaths report

On 6th September 2018, Christopher Murray, Assistant Coroner for Manchester South, opened an inquest into the death of George Foster Thompson who died on 23rd August 2018 at Tameside General Hospital, Ashton-under-Lyne, at the age of 86. The investigation concluded with an inquest which I heard on 8th January 2019. My conclusion was that Mr Thompson died as a consequence of natural causes.

In later life Mr Thompson developed an array of chronic health problems. In addition to being suspected to have dementia, he had diabetes mellitus, heart failure, ischaemic heart disease and high blood pressure.

In 2017, he moved into Firbank Lodge Residential Care Home. Over the course of his time there, he developed, and was treated for, a number of chest and urinary tract infections.

On 21st August 2018, staff at Firbank Lodge contacted Highlands and Trafalgar Square Surgery requesting a home visit as Mr Thompson had become unwell. The duty doctor who spoke to staff dealt with the call as what he termed in his evidence as a telephone “triage” call, and prescribed antibiotics following a discussion with a carer with a view to adding Mr Thompson to the home visit list the following day if his condition did not improve with the medication.

The following day, Mr Thompson’s condition deteriorated (notwithstanding three doses of oral antibiotics which had been delivered to Firbank Lodge) and was admitted to Tameside General Hospital by ambulance where he died on 23rd August.

A doctor treating Mr Thompson confirmed the medical cause of his death was:

1) a) Bronchopneumonia;
2) Vascular dementia, ischaemic heart disease, aortic stenosis, chronic kidney disease and Type 2 diabetes mellitus.

The evidence before the court was that, on the afternoon of 21st August 2018, there was only one doctor on duty for the practice as a whole. The evidence of the relevant clinician was that in addition to undertaking a (habitually) busy afternoon surgery, he was the only doctor available to deal with emergencies or clinical queries. In those circumstances and whilst the relevant clinician described his telephone call with the care home in terms of being a “triage” consultation, there was no resource in the practice for a home visit to be undertaken that afternoon even if considered indicated by the doctor.