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Investigation and inquest
On 9.12.24, I commenced an investigation into the death of Connor Nelson
The investigation concluded at the end of the inquest on the 18th November 2025
The conclusion of the inquest was a narrative as follows:
Connor died from hypoxic ischaemic encephalopathy, an un-survivable brain injury caused by a prolonged period of lack of oxygen, during a cardiac arrest. The arrest occurred on the Emergency Assessment Unit at Kings Mill Hospital (KMH) on 10.11.24. There was a significant delay in providing a necessary defibrillator shock during the arrest, which made a more than minimal, negligible or trivial contribution to his death.
The cardiac arrest was likely caused by a ventricular arrhythmia, secondary to congenital prolonged QT syndrome, which was undiagnosed in life, despite multiple opportunities to do so.
Lack of anti-sickness medication and a lack of Potassium replacement in the hours prior to the cardiac arrest, both also likely made a contribution to the development of the arrhythmia that led to the cardiac arrest, and to his death, as did his underlying health conditions.
Connors death was contributed to by neglect
Circumstances of the death
Connor died from hypoxic ischaemic encephalopathy on 30.11.24, at Kings Mill Hospital, following a prolonged cardiopulmonary arrest on 10.11.24. He had undiagnosed congenital prolonged QTc syndrome, which led to an arrhythmia and to his arrest.
The resuscitation provided at the time of his arrest was sub-optimal, with a delay of nine minutes in administering a necessary shock.
There were multiple opportunities to make the diagnosis of congenital Prolonged QT syndrome, prior to his final admission. There were repeated abnormal ECG findings of prolonged QTc from November 2022 onwards, but no necessary repeat ECGs when Connor was well, and no necessary cardiac follow up to arrange the cardiac investigations required to make the diagnosis.
Connor had significant issues with alcohol dependence and anxiety and depression, and it would have been challenging for him to manage the condition. However had it been diagnosed as it should have been, he and his family would have been aware of it, and perhaps family and professional support would have enabled him to change his lifestyle. Whilst this is a possibility, I cannot say a diagnosis in life would have probably prevented his death.
Coroner’s concerns
1. The lack of evidence of any improvement in the ability of Emergency Assessment Unit staff to respond effectively to a cardiac arrest
2. The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology team.
I am not reassured that necessary actions to address these serious issues identified are in place.
Information checked against the published report and official responses