John Keith William Shelley · Prevention of Future Deaths report

On 18th July 2013 I commenced an investigation into the death of John Keith William Shelley then aged 68. The investigation concluded at the end of the inquest on 31 July 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died on the 14th July 2103 from lobar pneumonia resulting from the ingestion of fairy liquid. The medical cause of death was:
1(a) lobar pneumonia

(1) John Keith William Shelley who had suffered brain injury at birth was wholly dependent upon the care of others.
(2) Following an assessment of his needs he was accommodated in a residential care home by the Health Board.
(3) Given his propensity to drink any liquids, certain steps were taken to try to prevent Mr Shelley consuming harmful substances.
(4) Despite this he was able to obtain and consume a quantity of fairy liquid from a bottled placed near to the kitchen window.
(5) Having consumed the fairy liquid he quickly became ill.
(6) There was a significant delay before advice was sought. The full extent of Mr Shelley’s illness was not adequately communicated to the person from whom advice was sought. Thus an inadequate assessment of the situation was made.
(7) Despite clear signs of Mr Shelley’s deteriorating health no contact was made with emergency services for some time.

That staff employed by the Health Board in caring roles should undertake basic first aid training and receive regular up-dates. There was information before the inquest that some staff at the residential unit had received no basic life support training and in relation to other staff members it was out-of-date.