Barry Joseph Dillon · Prevention of Future Deaths report

On 14 November 2013, I commenced an investigation into the death of Barry Joseph Dillon, aged 68. The investigation concluded at the end of the Inquest on the 4th day of March 2014. The conclusion of the Inquest was that Barry Joseph Dillon had died as a consequence of aspiration pneumonia due to dementia; the conclusion being that of natural causes.

Barry Dillon had been detained on Ward 19 at Burnley General Hospital, pursuant to Section 6 of the Mental Health Act 1983, and was transferred to the Royal Blackburn Hospital following seizures. Whilst at the Royal Blackburn Hospital he had suffered a number of aspiration pneumonias, finally succumbing on 13 November 2013.

I received evidence from ████████, a Specialist Speech and Language Therapist, who stated “There are currently insufficient resources to provide a comprehensive SLT service at the Royal Blackburn Hospital. The Royal College of Speech and Language Therapists’ guidelines recommend a two working day response time to referrals for a swallow assessment. This is not achieved by the SLT service at the Royal Blackburn Hospital and there is a risk assessment in place which is currently on the East Lancashire Hospitals Trust Corporate Risk Register with an accompanying business case identifying the resources required to address the shortfall in provision”.

Although Mr Dillon had been referred to the Speech and Language Therapy Service on 17 October 2013, no action was taken until 1 November 2013. I believe that whilst there remain insufficient resources to provide the service at the Royal Blackburn Hospital patients will continue to be at risk of the development of aspiration pneumonia which may prove to be fatal.