Mr Mohan Acharya · Prevention of Future Deaths report

On the 15/03/2018 I commenced an investigation into the death of Mr Mohan Acharya. The investigation concluded at the end of an inquest on 27/02/2020. The medical cause of death was 1A) Bilateral confluent bronchopneumonia 2) Acute renal failure. The narrative conclusion is detailed in section (4) below.

Mr Mohan Acharya died on 8ᵗʰ March 2018 at Northampton General Hospital as a result of bronchopneumonia causing sepsis/infection which led to hypovolemia which precipitated a cardiac arrest. Although bronchopneumonia or respiratory sepsis could not be excluded, Mr Acharya presented with none of the usual features and a reasonable clinician would not have diagnosed it. It was reasonable to focus on the potential cardiac problem on the basis of the clinical presentation. The hospital was under extreme pressure and was in an Opel 4 status; there were also a number of service failings. However, these factors did not more than minimally contribute to the death either singularly or in combination.

According to the Royal College of Emergency Medicine:-

1. Emergency department crowding is associated with increased mortality amongst admitted patients; and
2. Approximately 500 deaths per year are caused by overcrowded Emergency Departments.