Benjamin Paul Stanley · Prevention of Future Deaths report

On 24ᵗʰ May 2022 I commenced an investigation into the death of Benjamin Paul Stanley. The investigation concluded on the 15ᵗʰ November 2022 and the conclusion was one of Narrative: Died as a consequence of malnutrition caused by chronic pancreatitis contributed by liver cirrhosis and the complications of necessary antibiotic therapy. The medical cause of death was 1a) Multi organ failure; 1b) Malnutrition; 1c) Chronic Pancreatitis; II) Clostridium Difficile Infection, Liver Cirrhosis, Sepsis

Benjamin Paul Stanley developed chronic pancreatitis. He became severely malnourished as a direct consequence of his chronic pancreatitis. He was admitted to Stepping Hill Hospital on 11ᵗʰ May 2022 and was very unwell. He had become severely malnourished. It was identified that he had liver cirrhosis in addition to the chronic pancreatitis. He was treated but continued to deteriorate. He developed sepsis and was treated further. He was found to have developed clostridium difficile probably as a consequence of antibiotic therapy. He died at Stepping Hill Hospital on 19ᵗʰ May 2022.

The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department. The Inquest heard that the hospital had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment. The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester.

The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital. In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed.