John Dickinson · Prevention of Future Deaths report

On 17 August 2020, I commenced an investigation into the death of John Dickinson, aged 83. The investigation concluded at the end of the Inquest on 20th July 2021. The medical cause of death was:
1a) Urosepsis
1b) Klebsiella Oxytoca Infection
II) Diabetes Mellitus Type 2, Hypertension

The conclusion as to death was a narrative conclusion that John Dickinson died as a consequence of a naturally occurring disease in circumstances where earlier admission to hospital may have prolonged life.

John Dickinson was admitted to hospital on 23 June 2020 following multiple falls in the preceding 24 hours. He was diagnosed with a gall bladder infection and received antibiotic treatment. His condition improved during the course of his admission and on 11 July 2020 he was moved to Sunnyside Care Home Leeds to occupy a community care bed.

On 15th July 2020 a GP attended and advised “... ensure plenty of food and fluids, if reduce fluid intake call 999”. He was commenced on a course of antibiotics which was completed on 21st July 2020. It is not clear from the records what quantity of food and drink Mr Dickinson was consuming from this date due to deficiencies in the documentation. From 28th July 2020 Mr Dickinson began refusing food other than breakfast however there was no record as to his general presentation.

On 2nd August 2020 he was admitted to hospital in Leeds. The referral stated that he had had poor nutritional intake for the previous 48 hours. He was diagnosed with having acute kidney impairment, dehydration and markers suggesting an infection. He was diagnosed with having a urinary tract infection, separate to the gall bladder infection. Despite antibiotics and fluids his condition deteriorated and he was placed on palliative care whereupon he died on 9th August 2020.

(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.