Norman Leadbeater · Prevention of Future Deaths report

On 24 January 2024 an investigation into the death of Norman Leadbeater was commenced. The investigation concluded at the end of the inquest on 27 June 2024. I recorded a conclusion of Natural Causes. The medical cause of death was 1a) Aspiration Pneumonia 1b) Parkinsons Disease 2) Liver Cancer

Norman Leadbeater had a past medical history of advanced Parkinsons disease, vascular dementia and presumed liver cancer. Following a swallowing assessment on 10 November 2023, he was advised to have thickened fluids to prevent chest aspiration. He was admitted to Fairfield General Hospital on 27 November and diagnosed with aspiration pneumonia secondary to Parkinsons disease. His medications were altered to liquid and dispersible forms. He was readmitted to hospital on 7 January and diagnosed with a further aspiration pneumonia. Despite treatment, he deteriorated and died on 14 January 2024.

Mr Leadbeater had been in receipt of domiciliary care from Evolve Services since October 2023. The care included the administration of medication. When a concern was raised that the carers had not been thickening fluids appropriately, the Community Commissioning Team at Bury Council undertook an investigation and found that the prescribed thickener was not listed on the Medication Administration Record (MAR) and that the care plan in place for Mr Leadbeater did not contain sufficient detail for care staff to safely and correctly administer thickened fluids.

In February 2024 and following its investigation into the concerns regarding Mr Leadbeater’s care, Bury Council Community Commissioning Team recommended that Evolve Services undertake a number of remedial actions. This included an immediate management audit of MAR for those service-users in receipt of medication support and liaison with GPs and Pharmacists to ensure that the medication listed for each service-user is up to date and accurate.

The concern had that four and half months since the recommendation was made, Evolve Services have not yet completed the management audit of MAR for those service users in receipt of medication support. The representative from Evolve Services who attended the inquest was unable to provide the Court with a timescale for completion of this work or the number of service users this affects.