Douglas Kay · Prevention of Future Deaths report

On the 1st December 2014, I commenced an investigation into the death of Douglas Kay, aged 90 years. The investigation concluded at the end of the inquest on 14th August 2015. The conclusion of the inquest was one of Natural Causes

Mr Kay was an elderly man, but was reasonably fit for his age. He presented to Bassetlaw Hospital with bleeding from a duodenal ulcer on 16th November 2014. He was admitted, monitored and given medication to try and heal the ulcer. On the evening of the 22nd November, Mr Kay became suddenly unwell with clear evidence of active bleeding from the ulcer, with a blood stained vomit and black stools. This was a catastrophic bleed and despite attempts to resuscitate him, he died approximately 7 hours later. Throughout the period of his deterioration there was significant confusion about the arrangements for a possible transfer to Doncaster Hospital for further treatment.
The Trust completed an investigation report, produced an action plan, and submitted further reports during the Inquest. All these documents went some way to addressing concerns raised in evidence, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed.

• There remain significant confusion, and uncertainty about how, and when, to transfer a patient with gastrointestinal bleeding, with no clear agreed policy or procedure available within the Trust
• There are new arrangements for the provision of gastrointestinal bleeding service at Doncaster Hospital, but key Senior staff at Bassetlaw Hospital are not aware of how it operates, particularly out of hours.