Philip Jones · Prevention of Future Deaths report

On 12th October 2021 I commenced an investigation into the death of Philip Jones. The investigation concluded on the 30th May 2022 and the conclusion was one of Natural Causes. The medical cause of death was 1a) Bronchopneumonia; 1b) Motor Neurone Disease

Philip Jones, in February 2021 started to have symptoms that included difficulty in swallowing. He lost a significant amount of weight over the course of the following months and his overall health deteriorated. In September 2021 he was admitted to Tameside General Hospital and clinical assessment concluded he had Motor Neurone Disease. He was transferred to Salford Royal Hospital where he developed bronchopneumonia. He deteriorated and was discharged home. He died at his home address on 9th October 2021 from bronchopneumonia. Post-mortem examination confirmed the diagnosis of Motor Neurone Disease.

1. The Inquest heard evidence that there were significant backlogs in appointments to see a neurologist due to a national shortage of clinicians and appointments. In Mr Jones’ case this had not impacted the overall outcome but the Inquest heard evidence that this would not necessarily be the case in all patients. The Inquest heard that pre-pandemic, there was a backlog in existence at 3,500 patients waiting for a neurology appointment. The figure at the time of the Inquest was approx. 7,000;

2. The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult. This impacted the holistic view that clinicians needed of an individual patient. Whilst images could be shared there was no ability for notes for one Trust to be visible to a clinician at another Trust;

3. The Inquest heard that there were delays in communications from consultants to other clinicians e.g. GPs and patients following appointments/assessments due to a shortage of administrative support for consultants. This meant that important diagnostic/treatment information about patients was not shared expeditiously.