Leslie Alan Summerfield · Prevention of Future Deaths report

On 7th September 2015 I commenced an investigation into the death of Leslie Alan Summerfield do 15th February 1934. The investigation concluded on the 11th January 2016 and the conclusion was one of Accidental death. The medical cause of death was 1a Subdural Haematoma 1b Clostridium Difficile Infection, Previous Stroke: Anticoagulation Therapy .

He was admitted to Trafford General Hospital at the end of June 2015 and within the last two weeks of his life he suffered some relatively minor trauma which led to a subdural haematoma. The consultant pathologist concluded that the injury had occurred whilst he was a patient in the hospital.

The Consultant Physician giving evidence to me indicated that she felt he needed an urgent endoscopy and that such a facility used to be available on site at Trafford, and indeed the equipment and staff members are still there, but only for use as a planned facility, not as an urgent request. If this is the case, is it safe to continue to treat patients with this type of illness at a hospital where the Management has withdrawn this essential service? In fact he was transported by ambulance to and from the Manchester Royal Infirmary despite the fact that he was a very sick man. The urgent endoscopy was not done at the MRI and he was sent back to Trafford for a “planned” endoscopy to take place.
At the very least this caused him considerable unnecessary discomfort, and at worst may have weakened him such as to aggravate his pre-existing co-morbidities.