John SHROSBREE · Prevention of Future Deaths report

On 13th June 2019 I commenced an investigation into the death of John SHROSBREE aged 72. The investigation concluded at the end of the inquest on 25th September 2019.

The conclusion of the inquest was a narrative conclusion:

The deceased was admitted to Milton Keynes University Hospital on 4th June 2019 clearly unwell, there was a failure to recognise the serious nature of his condition and a failure to take the necessary steps to treat it. He went into cardiac arrest and suffered hypoxicbrain injury and died on 11th June 2019.

The deceased was admitted by his GP via ambulance to Milton Keynes University Hospital on the 4th June 2019 very unwell. His observations and tests confirmed he was unwell with a high potassium level, his observations were not reviewed, his care was not escalated to a higher level, he was transferred to a non-observable and unmonitored bay in the emergency department, there was a delay in starting treatment to reverse his condition and he was transferred for a CT scan when unstable. He suffered hypoxic brain damage following a hyperkalaemic cardiac arrest and died on 11th June 2019

My concern is that during the evidence it became clear that the problems encountered in the Emergency Department on 4th June 2019 were mainly brought about by staff shortages. I was told that staff shortages occur on a daily basis and I believe that as a result lives of this citizens of Milton Keynes are being put at risk and the problem should be addressed as a matter of urgency.