Andrew John Fallon · Prevention of Future Deaths report

On 26th November 2012 I commenced an investigation into the death of Andrew John Fallon born on the 18th June 1977. The investigation concluded at the end of the inquest on 23rd October 2013. The conclusion of the inquest was that he died from natural causes, the medical cause of death being 1a bronchopneumonia 1b post resuscitation of cardiac arrest 1c hypokalaemia due to gastroenteritis and Part 1 Beckers muscular dystrophy.

On the 9th November 2012 he was admitted to Stepping Hill Hospital with a history of four days vomiting and abdominal pain and was diagnosed as having gastroenteritis. Later that same day he suffered a cardiac arrest and although he was resuscitated he was left with severe neurological damage and needed full support on the ITU. He showed no improvement and ventilator support was withdrawn and he died on the 15th November.

1. I heard evidence from the medical staff and others that the staffing levels within the Emergency Department were such that the doctors simply could not cope with the volume of work, thus leading to inordinate delays in treating the patients. I was specifically informed that there were, as is frequently the case, numerous patients at the Emergency Department with what can only be described as minor or trivial complaints.
2. It appeared to me during the course of the evidence that a very effective solution/help would be for there to be a Primary care facility staffed by GP’s within or immediately adjacent to the ED. This would enable the triage nurse to allocate those minor conditions to the Primary care facility. This would then mean that those patients such as Andrew Fallon with severe health issues would not be kept waiting so long for treatment.