Geoffrey Gudgeon · Prevention of Future Deaths report

On 16/2/26, I concluded the inquest into the death of Geoffrey Gudgeon who died in Poldhu Nursing Home, Mullion on 1/12/24 at the age of 89.

I recorded the cause of death as
1a) Ischaemic stroke.

I recorded a conclusion that Geoffrey died from Natural Causes.

On 11 June 2024, Geoffrey suffered a spontaneous ischaemic stroke. He was admitted the next morning to West Cornwall Hospital where, after a CT scan, his diagnosis was confirmed. ████████, WCH consultant contacted the stroke unit at RCHT and ████████, clinical lead for the stroke service, felt it was clinically appropriate for Geoffrey to be transferred to Phoenix ward at RCHT. At that time, however, no beds were available on the ward.

Shortly thereafter, a request was made for a rehabilitation bed at Camborne & Redruth Community Hospital. Again, no bed was available.

Geoffrey’s presentation fluctuated. In early July, it was felt it would no longer be in his best interests to be transferred to CRCH due to low mood. On 30 July, approximately six weeks after admission to WCH, Geoffrey was transferred to Penhalllow reablement unit - on the family’s evidence, without prior discussion with them. He was seen by a stroke nurse on 5 August who felt Geoffrey’s needs were greater than the unit could meet. He was transferred the same day to Royal Cornwall Hospital. Two safeguarding referrals were made which culminated with a referral to the police.

On 15 August, Geoffrey was transferred to Poldhu Nursing Home where he remained until he died. The police have confirmed no criminal offence has been disclosed. The safeguarding investigations appear to have been closed after it was established he was in a suitable Home.

1) The inquest heard evidence from ████████ stroke consultant, that, at the time of these events, only 35% of patients were admitted to a stroke unit from an ED within 4.5 hours, while only 55% of patients were spending over 90% of their time on a stroke unit. Further, that there were approximately 80 admissions of stroke patients/month or about 900/year. The obvious concern was that there was a capacity issue in Cornwall concerning the timely admission and treatment of stroke patients.