John Turner · Prevention of Future Deaths report

On 7th June 2024, I opened an inquest into the death of John Turner who died on 23rd August 2023 at Tameside General Hospital, Ashton-under-Lyne, aged 73 years. The investigation concluded with the inquest which I heard on 27th September 2024.

A post mortem examination determined Mr Turner died as a consequence of:

1) a) Pulmonary Embolism;

1) b) Deep Vein Thrombosis.

At the end of the inquest, I recorded a conclusion of Natural Causes contributed to by Neglect.

Mr Turner died on 23rd August 2023 at Tameside General Hospital as a consequence of a Pulmonary Embolism due to a Deep Vein Thrombosis, neither of which had been identified when he previously presented at the hospital's Emergency Department on 20th August 2023.

Mr Turner first became unwell whilst on holiday in Greece and experienced a cough and following his return home, progressive breathlessness. A course of oral antibiotics prescribed by a staff member at the GP surgery did nothing to improve his symptoms, leading Mr Turner to attend the Emergency Department where he was assessed and sent home without any further treatment in circumstances where a D-Dimer test requested by the triage nurse was not undertaken

The court heard evidence as to a wide-range of factors ranging from demographics, difficulties in accessing primary care and increasing acuity of illness in an ageing population which have combined to create great pressure on hospital Emergency Departments.

In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs.

In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time.

In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced.