Paul Moroney · Prevention of Future Deaths report

On 3rd September 2014 I commenced an investigation into the death of Paul Moroney dob 7th November 1961. The investigation concluded on the 21st January 2015 and the conclusion was one of “He died from the abuse of alcohol”. The medical cause of death was 1a Dilated Cardiomyopathy 1b Chronic Alcoholism 11. Liver Cirrhosis and Steatosis

On the 27th August 2014 he attended at Tameside Hospital by ambulance . the ambulance proceeded to the hospital with full emergency equipment in operation, and the patient was given oxygen in the ambulance. Once at the hospital blood was taken and a bed-side X-ray was done. There was concern that he had a blood clot, and it was arranged that he should return to the hospital the following day for the administration of blood thinning agents.
Shortly after returning home, his breathing got worse and a second emergency ambulance was called. The ambulance staff asked the patient why he had discharged himself from hospital and he told them that he had been discharged by the doctors.

1. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded

2. Having been put on oxygen in the hospital, this was discontinued and he was sent home without his Oxygen saturations being monitored

3. When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels.