Joseph Hargreaves · Prevention of Future Deaths report

On 24th April 2020 I commenced an investigation into the death of Joseph Hargreaves. The investigation concluded on the 2nd November 2020 and the conclusion was one of Narrative: Died as a consequence of the complications of underlying swallowing difficulties.

The medical cause of death was 1a) Sepsis; 1b) Aspiration Pneumonia on a background of chronic swallowing difficulties; II) Congestive Cardiac Failure, Ischaemic Heart Disease, Hypertension

On 17th April 2020, Joseph Hargreaves had an unwitnessed fall at his care home. The precise circumstances are unclear. He was admitted to Stepping Hill Hospital where he was treated for sepsis due to aspiration pneumonia, caused by poor swallowing. He appeared to improve initially but deteriorated rapidly when transferred. He died at Stepping Hill Hospital on 17th April 2020.

The inquest heard that Mr Hargreaves was a long-term resident of the care home with significant swallowing issues and poor mobility. Following lockdown his family, who had been visiting most days, could no longer visit him. On his admission to hospital his family could not attend the hospital and they were unclear about the events in the home leading up to his admission.

The provision of information, about the events leading up to his admission; his baseline and underlying health issues, to treating clinicians was reduced. In his case it did not impact the outcome however it was clear from the evidence that it could in other circumstances cause significant challenges in delivering effective treatment quickly to vulnerable patients.