STEPHEN GOODHALL · Prevention of Future Deaths report

On 16th December 2013 I commenced an investigation into the death of STEPHEN GOODHALL d.o.b. 8th August 1934. The investigation concluded on the 24th April 2014 and the conclusion was one of ACCIDENTAL DEATH. The medical cause of death was 1a Pneumonia and 2 Lumbar Vertebral fracture

On the 19th October 2013 at his home address, Mr Goodhall fell on the stairs and fractured his lumbar spine. He was taken to Wythenshawe Hospital and admitted. Thereafter he contracted hospital acquired pneumonia on several occasions and on the 8th December the outreach nurse from ITU told his family that there was a bed for him in ITU, but then the ITU consultant declined to accept him, for reasons not made known to the family. He was subsequently taken to ITU on the 10th December when he remained hypotensive despite having had 11 litres of fluid, was developing a worsening metabolic acidosis, was oliguric, had a worsening kidney function and was again suffering a hospital acquired pneumonia. He died two days later.

There does not appear to be a clear policy in place to determine candecy and there appears to have been a contradictory message from the nursing and medical staff.