Pin
Get email alerts
Request correction
Investigation and inquest
On the 12th February 2015 Catherine McKenna, Assistant Coroner, commenced an investigation into the death of Toni Piel. The investigation was concluded at the end of the Inquest on the 26th May 2015. The conclusion of the Inquest was that the deceased died on the 23rd December 2014 at his home address, 65 Wood Park Court, Whitebank Road, Limeside, Oldham as a result of a head injury caused by a fall. The evidence did not disclose whether a head injury which occurred on 10 December 2014 and which resulted in treatment at The Royal Oldham Hospital or a separate unconnected injury caused his death, the medical cause of death being:
1a) Intracranial Haemorrhage
1b) Head Injury
1c) Fall
Circumstances of the death
The deceased was born on 5th March 1949 and was 65 years old at the time of his death on 23rd December 2014.
On the 10th December 2014 the deceased suffered an injury to the back of his head in a fall at his home address. He was taken to the Royal Oldham Hospital by emergency ambulance. The ambulance records outline a possible recurrent fall with the fourth fall that day. The deceased stated that he had had approximately 4 cans of lager.
On arrival in the emergency department it was noted that the deceased had a laceration to the back of his head approximately 5 inches, that he drank most days and that there was the possibility of recurrent falls. The injury was cleaned and closed with 4 sutures. The deceased was considered to be safe to be discharged home with head injury advice and wound care.
On the 23rd December 2014 one of the deceased’s neighbours contacted the police as he was unable to make contact with the deceased. Entry to the deceased’s flat was forced and the deceased’s body was found lying on the floor by the bed fully clothed.
A Post Mortem Examination was conducted by ████████ Consultant Histopathologist. He noted a large subdural haematoma in the middle and posterior regions of the brain and a prominent subarachnoid haemorrhage in both temporal lobes and cerebellum. He said the evidence was consistent with another injury suffered at The Royal Oldham Hospital 10 December 2014. In his opinion the possible explanations were that the fall which resulted in treatment at The Royal Oldham Hospital on 10 December 2014 had triggered a further fall which had led to his death or that he had suffered a fall which was not connected with the fall for which treatment was provided on 10 December 2014.
Coroner’s concerns
i) At the time the deceased was discharged home following the head injury on 10 December 2014 the deceased’s home circumstances were apparently not taken into account. Had such an assessment been made it would have been noted that there was no-one able to observe the deceased at home. The NICE clinical guideline 175 issued January 2014 recommends that this should be taken into account.
ii) No assessment of the risk factors in discharging the deceased was documented in the deceased’s records.
Information checked against the published report and official responses