Philip Taylor · Prevention of Future Deaths report

On 10th January 2020 I commenced an investigation into the death of Philip Taylor. The investigation concluded on the 25th November 2020, and the conclusion was one of Narrative: Died from an acute kidney injury caused by significant severe dehydration.
The medical cause of death was
1a) Acute Kidney Injury
1b) Dehydration
II) Dementia - Lewy Body, Pneumonia

Philip Taylor had Lewy Body Dementia. He resided in a residential care home. He became unwell with a chest infection. His fluid consumption dropped significantly. His level of dehydration was not recognised by the GP or the home. On 3rd January he deteriorated further and NWAS attended. He was severely dehydrated. He was transferred to Stepping Hill Hospital and arrived at 16:32 on 3rd January. At 16:44 he was triaged and scored 3 on NEWS 2. He was assessed to be seen within 1 hour. He waited in the corridor due to capacity issues and was not seen until 19:17. His family had repeatedly asked for him to be reviewed. Intravenous fluids were commenced. Blood test results showed a severe acute kidney injury due to dehydration. He remained in the Emergency Department until about 21:30 on 4th January as a result of bed shortages. His NEWS 2 scores showed a deteriorating picture. The observations were not repeated with the regularity set out in NICE guidance. He developed pressure sores as a result of a prolonged period of time on a trolley in the hospital. Following transfer to the Acute Medical unit he continued to deteriorate, despite intravenous fluids. On 6th January 2020 he died at Stepping Hill hospital.

FOR CCG

1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons.

• The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were.
• The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred.

FOR DEPARTMENT OF HEALTH AND SOCIAL CARE

2. The paramedic attending was a newly qualified paramedic and as a result was using the national pathfinder tool. Mr Taylor was scoring for sepsis on the NWAS observations. However, the crew took well over an hour to leave the care home. The inquest heard that newly qualified paramedics relied on the national pathfinder tool which did not make it clear the need for an immediate expedited transfer to hospital in such circumstances. More experienced paramedics used the Manchester triage tool which was far more explicit. The inquest was told that NWAS had recognised the issue with the national tool and were adjusting their practices to avoid the risk. However, it was not clear if other Ambulance Trusts had made similar adjustments for newly qualified paramedics.

FOR DEPARTMENT OF HEALTH AND SOCIAL CARE AND CQC

3. The staff in the care home were not medically qualified. The inquest heard that their ability to recognise and respond to an escalating risk of dehydration was limited. There was no national guidance to assist care home staff in understanding how to recognise; respond and escalate the risk of dehydration.