Michael Barry Richardson · Prevention of Future Deaths report

On 18 March 2014 I commenced an investigation into the death of Michael Barry Richardson aged 66 years. The investigation concluded at the end of the inquest on 18 March 2015. The conclusion of the inquest was that the medical cause of death was 1a Bronchopneumonia, 1b Pulmonary Fibrosis, 2 Pulmonary hypertension and Ischaemic Heart Disease and that Mr Richardson died from natural causes.

Mr Richardson was admitted to the James Paget University Hospital on 24 October 2013 following a deterioration in his lung disease. He was diagnosed as suffering from an infective exacerbation of his pulmonary fibrosis and a community acquired pneumonia. Despite treatment he arrested and died on 27 October 2013. On admission a MUST screen was carried out by a student nurse with a score of 0.

There was within Mr Richardson's records an ambulance crew report which recorded that Mr Richardson was said to have not eaten for 5 days. In evidence before me it was confirmed that the ambulance report would have been available to the person who undertook the MUST screen. It also appeared that this may not have been reviewed at the time. If it had been reviewed the evidence given before me was to the effect that the information might have led to a MUST score of 2 which would in turn have led to a referral to dietician services. Although the expert evidence was that Mr Richardson's nutrition did not play a material part in his death, I am nevertheless concerned that in different circumstances a failure to follow up information or review the ambulance record and/or any other records with which a patient is admitted and so miss the information could affect the outcome for the patient and that there is therefore a risk of future deaths.