Matthew Crowley · Prevention of Future Deaths report

On 17th June 2015 I commenced an investigation into the death of Matthew Crowley, 39 years. The investigation concluded at the end of the inquest on 17th February 2016. The conclusion of the inquest was that Matthew Crowley died at 06.47 on 10th June 2015 at Pembury Hospital following a transfer from Maidstone Hospital. He had presented to Maidstone Hospital at 17.08 on 9th June 2015 acutely unwell. Supportive treatment was given at 22.00 to which he initially responded but he thereafter deteriorated and supportive measures were not escalated. He succumbed to an overwhelming sepsis caused by a pseudoaneurysm of his left thigh which had developed as a result of intravenous drug abuse.

Matthew Crowley was brought by ambulance to Maidstone Hospital at 17.08 9th June 2015. He was triaged approximately 40 minutes later and found to have a PAR 5. He was first seen by a doctor at 19.28 and found to be septic with acute kidney injury, liver and respiratory failure. He had a mass in his upper thigh and an oedematous mottled leg. Supportive measures were not put in place until 22.00 as a result of difficulties in placing a peripheral line. Options were discussed to transfer him to a vascular centre, ITU or the surgical site of hospital at Pembury. He continued to deteriorate during this time, measures were not escalated. A decision was made 9 hours after his arrival to transfer him to Pembury. He died some 2 hours after arrival. A post mortem established the cause of death as 1a sepsis, 1b pseudoaneurysm left thigh, 1c intravenous drug abuse

(1) A Rapid Access Treatment Protocol (RATT) was not in operation as a result of a busy A&E department which was short staffed. This resulted in a delay in the triage
(2) The patient was not seen by a doctor for 2 hours 20 minutes despite being PAR 5 and requiring therefore an immediate review by a senior doctor
(3) There was a delay in ownership and onward management of the patient which resulted in timely decisions not being made. On call consultants responsible for those decisions were not aware of the patient deteriorating because they did not personally review the patient and were not informed of, or did not secure updated information themselves of how acutely unwell the patient was.
(4) Despite a vascular site declining to accept the patient until his renal function was optimised and a CT angiogram performed, a delay was caused by enquiries being made whether a second vascular site would accept the patient
(5) The ITU of the hospital to which the patient was transferred were not informed of the transfer