Michael Kevin Amesbury · Prevention of Future Deaths report

On 6th December 2022 I commenced an investigation into the death of Michael Kevin Amesbury. The investigation concluded on the 25th May 2023 and the conclusion was one of Narrative: Died from a combination of bronchopneumonia (not diagnosed until after death) and aspiration of gastric contents exacerbated by heart failure for which he was awaiting assessment regarding his suitability for surgical intervention. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy

Michael Kevin Amesbury had an extensive cardiac history. He was becoming increasingly unwell as a consequence. On 24th October 2022 he had a trans-oesophageal echocardiogram that confirmed he had severe mitral regurgitation. He was referred to Wythenshawe Hospital for surgical assessment. Whilst awaiting assessment he became increasingly unwell. He was prescribed Dapagliflozin medication which led to a rapid rise in his ketones and he became increasingly unwell. He was admitted to Tameside General Hospital on 30th November 2022 .Whilst an in-patient at Tameside General Hospital he became unresponsive. Cardiopulmonary resuscitation was undertaken during which there was severe vomiting of gastric contents. He died at Tameside General Hospital on 30th November 2022. Post-mortem examination confirmed he had died with bilateral bronchopneumonia (not diagnosed in life) in combination with extensive aspiration of gastric contents. He had extensive evidence of heart failure which on the balance of possibilities contributed to his reduced physiological reserves and to his death.

1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services;

2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient.