Thomas Anthony Collins · Prevention of Future Deaths report

On 21st July 2015 I commenced an investigation into the death of Thomas Anthony Collins dob 9th October 1970. The investigation concluded on the 18th November 2015 and the conclusion was one of Accidental Death. The medical cause of death was 1a Sepsis and multi-organ failure 1b Pneumonia and Adult Respiratory Distress Syndrome 1c Fractured Ribs 1 1 Alcoholic Liver Disease .

Mr Collins lived in a Care Home as a result of his ill-health due to drinking excess alcohol for many years. In the home, on the 22nd June 2015, he fell and damaged his chest. He was attended by his own GP on the 24th June 2015, who, despite the obvious serious and intense pain felt by the deceased, declined to admit him to hospital. A paramedic attended him on the 22nd June 2015, and this paramedic felt it necessary to obtain an opinion from a doctor, so he contacted the Out of Hours Service even though the GP surgery where the deceased was registered was in fact open. The OOH GP then purported to give informed advice to the paramedic, even though he could not examine the patient. It was decided not to take the patient to hospital.
The cardio-thoracic surgeon gave evidence to me that if the patient had been taken to hospital on the 22nd when the injury occurred, “he would still be around today”
On the 25th June he was eventually taken to Tameside Hospital, and on the 26th he was transferred to the Tertiary Unit for chest medicine, was then in the ITU until he was transferred back to Tameside on the 6th July 2015, and he died there on the 15th July.

1. The attending paramedic lacked the confidence to make a clinical decision, which I accept can happen, but he then contacted the Out of Hours doctors who had no knowledge of the patient, rather than his own GP Practice. When, in what circumstances, should a paramedic seek the advice of a doctor who is not in attendance, as to whether the patient is to be taken to hospital?(NWAS)

2. The GP attended the patient on the 24th June and she assumed that he had been seen by a doctor on the 22nd because the record showed that he had been seen by a “practitioner”. In fact he had only been seen by the paramedic. This assumption very much detrimentally influenced her subsequent decision making.(Haughton Thornley Medical Centres)

3. On the attendance on the 24th, the doctor noted that the patient had had a fall, but she did not realise it was an unwitnessed fall, so the force and detail thereof was not known by anyone. She noted that the patient found it “was too painful for him to move or to sleep”, and she said it was “evident that he was in agony with pain for him to turn in bed” (sic). She did not ascertain from the care staff that the patient’s chest was “pulsating when breathing”, a classic sign of a flail chest. She conceded that facing the same situation now, she would have admitted him to hospital. This is clearly an area where further training is required.(Haughton Thornley Medical Centres)