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Investigation and inquest
On 9TH December 2016 I commenced an investigation into the death of Derrick Lawrence Brocklehurst. The investigation concluded on the 17th May 2017 and the conclusion was one of:
Narrative: Died from a recognised complication of immobility the reasons for which are unclear.
The medical cause of death was: 1a) Pulmonary Embolus; 1b) Deep Vein Thrombosis; 1c) Immobility; II Cerebrovascular Disease, Ischaemic Heart Disease, Pressure Ulcers
Circumstances of the death
On the 14th October 2016 Derrick Brocklehurst was admitted to Tameside General Hospital via ambulance. NWAS raised safeguarding concerns. At A&E he was examined and discharged home. A social care package was in place. On the 16th November 2016 Mr Brocklehurst and his wife met social services at their home address. They stopped all social care. They were considered to have capacity. Social care stopped subsequently. On the 28th November 2016 NWAS were called to the address. Derrick Brocklehurst was found in his chair incontinent. There was faeces and urine covering the chair. He indicated he had been immobile since his return from hospital. He was admitted to Tameside General Hospital. He had a grade 4 pressure ulcer to his sacrum and his left heel. He was given anti coagulation therapy. On the 2nd December 2016 he died from a pulmonary embolus.
Coroner’s concerns
1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
2. No discharge summary was provided by Tameside General Hospital to the GP after the deceased was seen in A and E.
Information checked against the published report and official responses