Michael Lawrence HACKER · Prevention of Future Deaths report

On 16th January 2015 I commenced an investigation into the death of Michael Lawrence HACKER, Aged 66. The investigation concluded at the end of the inquest on 6th May 2015. The conclusion of the inquest was Natural Causes with the medical cause of death being 1a) Gangrene of the foot and 1b) Type 2 diabetes mellitus

Mr. Hacker was an eccentric man who refused hospital admission to treat his gangrene. He was assessed as lacking capacity to refuse admission on 19th December but died on 28th December 2014 at his home address before hospital admission

1. ████████ an Advocacy and Locum Consultant IMCA expressed in evidence his concerns in relation to the ambulance service in this particular case. I heard evidence that South West Ambulance Services Trust had attended Mr. Hacker previously to take him to hospital for treatment of his gangrene and had not been successful in persuading Mr. Hacker to go with them.

████████ contacted ████████ from the South West Ambulance Services Trust before and after Mr. Hacker's death to be told that if an ambulance turned up at the property then there was a protocol in place that meant that the crew would not use restraint or apply force if Mr. Hacker did not want to go with them. ████████ expressed concerns as to the Trust's policy around the Mental Capacity Act.

If Mr. Hacker had been taken to hospital sooner he may or may not have received treatment depending on a number of factors including his capacity to make decisions. I did not make any criticism around the ambulance service in this case however it did raise a concern with me about prevention of future deaths.

I am therefore writing this report to ask that you consider your training and policy around the Mental Capacity Act