David Aughton · Prevention of Future Deaths report

On the 27th of January 2016 I commenced an investigation into the death of David Aughton aged 63 years. The investigation concluded at the end of the Inquest which was concluded on the 11th May 2016. The conclusion of the Inquest was that David Aughton had died from an Accidental Death.

In August 1999 David Aughton fell and sustained a severe traumatic brain injury which led to epileptic seizures. Those seizures were controlled by lamotrigine and sodium valproate. On the 21st December 2015 he was admitted to the Royal Blackburn Hospital for a cystoscopy which was performed under general anaesthetic. Whilst at the Royal Blackburn Hospital he had not been administered his anticonvulsant medication such that on the 22nd December 2015 he had a grand mal convulsion which caused aspiration pneumonia. Thereafter he remained unwell until he died on the 25th January 2016.

That despite the fact that his regular medications including lamotrigine and sodium valproate were recorded in his medical records, those medications had not been dispensed, leading to a grand mal convulsion it was apparent that there was no mechanism in place to ensure that essential medications were prescribed, dispensed and administered.