John Richard Hartey · Prevention of Future Deaths report

On 3rd April 2024, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of John Richard Hartey who was found dead at his home on 20th October 2023, aged 57 years. The investigation concluded with an inquest which I heard on 3rd May 2024.

A post mortem examination determined the medical cause of Mr Hartey’s death as being:-

1) a) Congestive cardiac failure;

b) Hypertensive heart disease;

c) Type 1 Diabetes Mellitus

II) Acute bronchitis and transplant immunosuppression

The conclusion of the inquest was a Narrative Conclusion of natural causes contributed to by recognised complications arising from transplant immunosuppression.

Mr Hartey was found dead at his home on 20th October 2023 as a consequence of congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus. His death was contributed to by acute bronchitis and transplant immunosuppression.

The court heard evidence to the effect that in the days prior to his death, Mr Hartey’s General Practitioner had made an Urgent Referral to the local District Nursing service which was received on 19th October 2023. Mr Hartey was allocated the first available appointment which was not until 23rd October 2023.

It is a matter of concern that a national shortage of District Nurses / Community Specialist Practitioners can lead to a delay in patients being seen in accordance with their needs.