Keith Hodson · Prevention of Future Deaths report

On 20 July 2022, I commenced an investigation into the death of Keith Hodson, aged 68 years. The investigation concluded at the end of the Inquest on 5 April 2023. The conclusion of the Inquest was narrative (see 4 below).

Mr Hodson had a complex medical history. There were delays prior to an ambulance being called, in connection with the attendance of the ambulance, on admission to hospital and subsequently in connection with appropriate treatment.

(1) I am advised that an appropriate Triage System is not always adopted in practice at Accident and Emergency.

(2) Without the adoption of a Triage System taking place escalation of care cannot meaningfully take place.

(3) I am advised that on occasion appropriate senior oversight does not occur, this is required to identify when a patient has not been appropriately assessed.

(4) S.I. reports are not signed off in a timely fashion by a responsible individual.

(5) Communication with the next of kin appears not to have occurred in a timely fashion.

Evidence given at the Inquest identified:
The Ambulance crew pre-alerted A and E, but the patient was not triaged using the Manchester Triage System, resulting in missed opportunities to identify the patient’s clinical priority. There was subsequently inadequate monitoring.
The degree of timely candour with the family is unclear and clarification is required in this regard.
It is acknowledged that delays of substance occurred prior to attendance at A and E, but this increases the importance of early assessment and triage procedure.