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Investigation and inquest
On 23rd July 2021 I commenced an investigation into the death of Mr Ian Cockfield, a man aged 53 years old. I opened an inquest on the 28th July 2021, the inquest was heard, before me on 24th May 2022.
The conclusion arrived at was a narrative conclusion;
“Mr Ian Michael Cockfield died in hospital on 12th July 2021.
At the time of his death he was receiving involuntary inpatient treatment for mental health issues. During that admission he underwent medical investigations that resulted in a preliminary diagnosis of metastatic liver and abdominal cancer.
On the evening of the 12th July 2021 Mr Cockfield collapsed requiring emergency cardiac treatment. Mr Cockfield was taken by ambulance to the major trauma centre where he subsequently sustained a cardiac arrest, despite resuscitative efforts he was declared dead that evening at 22.06.”
The medical cause of death was found to be;
1a Carcinomatosis
Circumstances of the death
See narrative conclusion above
Coroner’s concerns
1. On Sunday 11th July 2021, Mr Cockfield was discharged from hospital after treatment. The patient was discharged to a mental health ward at a different hospital. Upon arrival at the mental health ward at 16.00hrs, a review of the patient’s falls risk assessment was not undertaken. The following day, Mr Cockfield suffered a fall whilst mobilising, unsupervised by staff. Mr Cockfield sustained a serious laceration to his head.
Information checked against the published report and official responses