STUART ARRON COLLINS · Prevention of Future Deaths report

On 25th October 2012 Mr Sheffield, the Senior Coroner, commenced an investigation into the death of STUART ARRON COLLINS, then aged 37. The investigation concluded at the end of the inquest on 15th November 2013. The conclusion of the inquest was Misadventure, the medical cause of death being Ia) hypoxic brain injury, Ib) cardiorespiratory arrest, Ic) alcohol toxicity and II) effects of diazepam & chloriazepoxide.

1. Mr Collins was intoxicated & fully conscious when he was taken to the A&E department at James Cook University Hospital at approximately 00.45 on 9.10.12.
2. Whilst at hospital it is likely he consumed further alcohol, most likely to be in the form of alcohol hand sanitiser gel, without the knowledge of the hospital staff.
3. He was discharged from the hospital at approx. 04.30 with a reduced level of consciousness.
4. He was taken by police to 3 Farne Walk, Guisborough.
5. Shortly after his arrival at the address he slipped into unconsciousness and suffered cardio respiratory arrest.
6. Mr Collins was transported back to James Cook University Hospital arriving at approximately 06.30.
7. He passed away at the hospital later that same day.

1. There appeared to be a degree of uncertainty as to whether Mr Collins was assessed upon his arrival at the A&E department at James Cook University Hospital ("the hospital")at approx. 00.45 or whether information previously obtained by paramedics was utilised in lieu of an assessment on arrival.
2. It was stated that Mr Collins should have had hourly nursing observations taken during his first admission to A&E on 9.10.12, ie between 00.45 and his discharge at 04.30, but none were taken.
3. Evidence was given that Mr Collins was added to the whiteboard in the A&E dept but that the information regarding the frequency of his nursing observations was not. It was stated that this led to no nursing observations being taken during his first time at A&E on 9.10.12
4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date. There was no apparent recording about Mr Collins’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach.
5. Evidence was given that the hand sanitiser gel was collected from the A&E department. However further evidence was given that the collected hand gels (estimated at 20 in number) were placed on the nurses station very close to Mr Collins’s cubicle. There was contradictory evidence as to whether Mr Collins could have accessed the hand gel from the nurses station.