Stephen George Coulson · Prevention of Future Deaths report

I concluded the inquest into the death of Stephen George Coulson on 4th October 2017 and recorded that he died from:

1a Hypoxic brain injury
1b Acute left ventricular failure
1c Idiopathic left ventricular hypertrophy on background of opioid toxicity

The deceased was admitted to Manchester Royal Infirmary on 30th December 2015 with abdominal pain. He had a complex past medical history which included operations for diverticular disease and a twisted bowel. He had also sustained severe spinal & nerve damage following a fall for which he was on long term opioid treatment including oral Oramorph and Fentanyl patches. On the 31st December 2015, following review by the Colorectal Surgical Team, his Fentanyl patch prescription was increased from 50mcg to 75mcg with a view to discharging him home with subsequent follow up for a pre-arranged colonoscopy. The deceased had been noted to be self-administering his own Oramorph whilst he had been in the hospital ward. Prior to his discharge a 75mcg Fentanyl patch was applied, though there is no record of his current 50mcg patch having been removed as was required by Trust policy. Later that morning he had telephoned his wife in a somewhat confused and agitated state. The deceased’s wife queried whether he should be discharged in that state and was so informed by the nursing staff. There was a policy in place at Manchester Royal Infirmary at the time such that patients exhibiting a change in presentation and/or symptoms of confusion required clinical observation before being discharged. It has been documented that the nurse had discussed this with the House Officer on call who suggested it would be due to the increased dose of Fentanyl. Despite this concern being raised the deceased was not seen or reviewed by any member of the surgical team prior to his discharge on December 31st. Nor was this lack of review escalated to a senior member of the surgical team. The deceased required assistance from his wife to reach his bedroom at home. The deceased was awoken by his wife at 23.30hrs on December 31st 2015 as they had been agreed earlier so that they could see the New Year celebrations, but he stated that he was too tired and sleepy. At 03.00hrs his wife awoke to find the deceased unwell, an ambulance was called and the deceased was found to be in cardiac arrest. Resuscitation was commenced and he was taken to the Manchester Royal Infirmary. He was admitted to the ICU where despite treatment he died on 1st January 2016.
A High Level Investigation conducted by the Trust found that no lessons needed to be learned. However, during the course of the inquest it became apparent from the evidence that lessons could be learnt by the Trust.

1) Controlled drugs – the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs

2) Observation policy – the lack of escalation of the need to admit patients for observation and review should they fulfil the criteria to require continued observation / review prior to discharge

3) High Level Investigation – the witness did not accept that any lessons could be learnt from the investigation surrounding the death of the deceased.