Andrea Franzosi · Prevention of Future Deaths report

On the 13th November 2017 I commenced an investigation into the death of Andrea Franzosi. The investigation concluded at the end of the inquest on the 24th October 2018. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Cardiac failure, 1B Necrotising Aortic Valve Endocarditis, 2 Chronic Obstructive Pulmonary Disease and Emphysema

Mr Franzosi, was a 52 year old man who presented to the Emergency Department at hospital on the 8th November 2017 with “flu-like” symptoms which he reported experiencing for two weeks. He had also suffered three episodes of central chest pain which was associated with shortness of breath. Mr Franzosi was diagnosed with pleurisy and discharged home on oral antibiotics. He was not admitted for further investigations. As a result his endocarditis was not diagnosed, and he did not receive treatment for this condition. This amounted to neglect which contributed to the cause of death. At approximately 11.21 hours on the 9th November 2017 Mr Franzosi collapsed whilst out with a friend. Emergency services attended and despite extensive resuscitation efforts, Mr Franzosi was pronounced deceased at 13.55 hours.

(1) The level of supervision of junior Doctors on the ward. In particular, when a patient is discharged without being examined by a more senior practitioner.