Eric Albert Gaskell · Prevention of Future Deaths report

On the 10th November 2015 I commenced an investigation into the death of Eric Albert Gaskell, born on the 24th October 1966.

The investigation concluded at the end of the Inquest on the 3rd February 2016.

The Medical Cause of Death was:-

1a Ischaemic Heart Disease
1b Coronary Artery Thrombus
1c Coronary Artery Atheroma

The conclusion of the inquest was Natural Causes.

On the 6th November 2015 Mr Gaskell attended at the Royal Bolton Hospital, Bolton complaining of chest pain. Following assessment, which included an ECG and blood tests with normal results, he was discharged later that day from the Accident and Emergency Department with a presumed diagnosis of stable angina. Upon discharge he was advised to contact his General Practitioner over the course of the next few days. On the 8th November 2015, during his work as a recovery vehicle driver on the M60 motorway, Mr Gaskell collapsed. He was taken to the Salford Royal Hospital, Salford where he died.

1. During the inquest evidence was heard that:-

i. The Accident and Emergency Department at the Royal Bolton Hospital carries a stock of medication to treat patients who attend their department and are discharged without formal admission. Only certain medication however is stocked and antianginal medication is one of the medication that is not stocked by the Department. If a patient therefore requires such medication, or any other that is not stocked, a prescription must be issued by the treating Doctor in the Accident and Emergency Department.

ii. In accordance with the current policy at The Royal Bolton Hospital, Doctors are only permitted to issue Hospital specific prescriptions, which can only be used at the Pharmacy at the Royal Bolton Hospital. They are not allowed, under the current policy, to issue a standard prescription, known as an FP10. They were able to issue an FP10 until a few years ago when the Hospital policy changed.

iii. The Pharmacy at the Royal Bolton Hospital is not a 24 hour Pharmacy. Evidence was given at the inquest that the Pharmacy is only open Monday to Friday 8am to 5.15pm, Saturdays from 9am, but the closing time was not known, and some Sundays when there is a demand for it to be open when the hospital is busy, such as the winter months.

iv. If a patient attends the Accident and Emergency Department of the Hospital and requires medication to be prescribed outside of the opening times of the Hospital Pharmacy, they will not have access to certain medications that are not carried by the Department, some of which could be lifesaving medication, as the Doctors are unable to issue a prescription to be used outside of the Hospital Estate. They can be given a Hospital specific prescription by a Doctor but would have to wait for the Hospital Pharmacy to open and collect it. So potentially a patient who attends the Accident and Emergency Department at the Royal Bolton Hospital on a Saturday evening in summer months for example, would not have access to medication that they require until the Monday morning when the Pharmacy is open.

v. Evidence was given that medication can prevent death and therefore it is possible that allowing access to medication 24 hours a day, whether that be by ensuring the Pharmacy is open 24 hours a day, or by allowing Doctors to issue a FP10 prescription, could prevent a future death.

2. I have concerns with regard to the following:-

i. Due to the current policy adopted by the Royal Bolton Hospital regarding the prescribing of medication, a future death could occur if a person is not given 24 hour access to medication that they require and I therefore request that a review be conducted by the Royal Bolton Hospital of their policies and procedures in respect of the prescribing at the Hospital.