Maurice Camfield · Prevention of Future Deaths report

On the 17th July 2013 I commenced an investigation into the death of Maurice Camfield, aged 71 years. The investigation concluded at the end of the Inquest on 1st April 2015. The cause of death was 1(a) Septicaemia due to 1(b) Perforated gangrenous cholecystitis and 2) Traumatic brain injury, diabetes mellitus and HIV infection, The conclusion which was a Short form was Accidental Death.

Maurice Camfield's medical history was that of suffering from back pain, type 2 diabetes and chronic obstructive pulmonary disease.

On 21st April he was involved in a road traffic collision in Bangkok whilst riding a motor cycle which caused him to suffer a traumatic brain injury. He was repatriated to the United Kingdom on 16th May 2013 where he was admitted to Pinderfields General Hospital, Wakefield.

The injuries he had sustained in Bangkok were subdural and subarachnoid haemorrhages, fractured ribs, left obstructive uropathy and hydronephrosis and dilatation with linear sulcrure. He developed post injury agitation and seizure activity and he was transferred to the stroke unit where a new diagnosis of HIV was made.

Mr Camfield was deemed ready for rehabilitation and was transferred to Dewsbury District Hospital for stroke rehabilitation where his condition deteriorated. On 27th June 2013 he was transferred to the intensive care unit at Dewsbury Hospital where he developed sepsis. He required blood pressure support and inotropes and he was fed by a nasogastric tube.

On 5th July 2013 he was transferred back to Pinderfields General Hospital but became immediately unresponsive on the journey and died in the ambulance.

I heard evidence at this Inquest from ████████ a Consultant in Neurological Rehabilitation who expressed the view that it was important that in Mr Camfield's case that those involved in his care and treatment should do so strictly in accordance with the agreed plan which dictated that he should have one to one nursing care at all times. ████████ stressed the importance of doing what was in our care plan which did not happen in Mr Camfield's case.