John Michael Bailey · Prevention of Future Deaths report

On 8 April 2011 I commenced an investigation into the death of John Michael Bailey, who was 60 on 10th February 2013. The conclusion of the inquest was that Mr Bailey died on 6th September 2013. The conclusion was that Mr Bailey died from a cardiac arrest, because of a lack of awareness of the symptoms of his condition.

Mr Bailey died of a cardiac arrest. An arteriovenous fistula (AVF) was used to treat cardiac? [████████] associated with it (occurring in between 2 and 4% of cases) with the risk rising in [████████]. Cases have been reported where the AVF is [████████] but it was not [████████].

(1) The absence of a robust system to ensure that patients who have an arteriovenous fistula are provided with clear information about the risks and complications, however the following may be worthy of consideration:

1. The National Care Quality Commission? is the management of that drug between the Trust and the management of Arteriovenous fistula? The specifics of that Protocol are alleged to be unclear.
1.1. The guideline for dealing with patients with Arteriovenous fistulas, management of Arteriovenous fistulas and secondary care physicians.
1.2. The protocol on the risk of the fistula? which should be carried out at each [████████].
1.3. The protocol provided to patients may extend the period.

(2) There was also inconsistency between the information provided by [████████] and [████████]. This inconsistency resulted in the circumstances of this case.

(3) Is it possible that a lack of consistency between different areas may also give rise to a risk where health care practitioners transfer jobs between those areas.