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Investigation and inquest
On 10th August 2012 I commenced an investigation into the death of Margaret Walker, who was 97 years of age. The investigation concluded at the end of the inquest on 14th March 2014. The conclusion of the inquest was that Margaret Walker died of natural causes. The medical cause of death was 1a) Acute Myocardial Ischaemia 1b) Coronary Artery Atheroma
Circumstances of the death
On the 4th August 2012 Margaret Walker, who was diabetic was admitted to the Sephton Unit at Leigh Infirmary as a detained patient under the terms of the Mental Health Act. At or about 6am on the morning of the 7th August 2012, Margaret Walker was found unresponsive in bed on the Sephton Unit. She was showing no sign of life. Cardiopulmonary resuscitation was commenced. A defibrillator was obtained but was not used prior to the arrival of ambulance personnel at or about 6.16am. Ambulance personnel continued resuscitation efforts and applied a defibrillator which did not reveal any heart rhythm. There is no evidence that the earlier use of a defibrillator would have prevented Margaret Walker's death. Margaret Walker was taken by ambulance to the Royal Albert Edward Infirmary in Wigan where her death was diagnosed. Her diabetes care during the time that she was a detained patient on the Sephton Unit was inconsistent. The inconsistencies in her care did not cause or contribute to her death from Coronary Artery Disease.
Coroner’s concerns
(1) Following Mrs Walker’s admission to the Sephton Unit at Leigh Infirmary as a detained patient on 4th March 2012, details of her previous medication regime for her diabetes were not sought until the 6th August 2012. When these details were obtained on the 6th August 2012, information concerning the medication was passed to relevant clinical staff but information concerning what blood test results were acceptable for her was not so passed.
(2) Information concerning Mrs Walker’s medical condition and blood test readings was not appropriately recorded in her clinical notes.
(3) When Mrs Walker was found unresponsive at approximately 6.00am on the morning of the 7th August 2012, cardio-pulmonary resuscitation was appropriately commenced and continued and a defibrillator was obtained. However the defibrillator was not applied prior to the arrival of ambulance personnel who then applied their own defibrillator, which did not reveal a heart rhythm suitable for a shock to be given.
Information checked against the published report and official responses