Mr Vinod Kumar · Prevention of Future Deaths report

On the 22 August 2016, I commenced an investigation into the death of the late Mr Vinod Kumar. The investigation concluded at the end of the inquest on 12 October 2016. The conclusion of the inquest was a short narrative conclusion of accidental death.

The cause of death was:

1a Multi-Organ Failure
b Group A Streptococcus Septic Shock
c Necrotising Fasciitis secondary to laceration sustained from fall

i) Mr Kumar was a very active and healthy family man who attended the gym and kept fit.

ii) On or around the 4 August 2016, he was complaining of feeling unwell with flu like symptoms. Unsually for him, this resulted him taking time off work.

iii) The following day he had a fall at home and sustained a graze to his right arm/elbow. His condition continued to decline and he attended New Cross Hospital on the evening of the 9 August 2016 after previously seeing an out of hours GP who suggested he had a viral infection which would resolve in several days.

iv) In the Accident and Emergency Department, he was initially seen by a Triage nurse who categorised him as a level 4 (least urgent) and took his history including a fall and swollen/painful arms.

v) He was seen later that night by a Doctor and after blood tests it became apparent he had a serious infection/sepsis.

vi) After further tests and x-rays, a fracture was ruled out and at this stage he was extremely ill and in multi-organ failure.

vii) His condition declined further and sepsis secondary to necrotising fasciitis was diagnosed.

viii) Despite surgical intervention to remove the infected tissue, he died shortly after the surgery on the 10 August 2016.

ix) On the balance of probability, the likely source of necrotising fasciitis was the graze on the arm injury.

1. Evidence emerged during the inquest that when he was seen initially by the Triage nurse, that too much emphasis and reliance was placed on the significance of the fall/trauma. Evidence of potential infection (swelling to his arms) resulted in no further observations or blood tests done until some three hours later.

2. Evidence from the A and E Consultant emerged from the inquest which suggested that it would have been good practice to keep the patient under further observation before determining his level of priority in terms of categorisation.