Terence Briney · Prevention of Future Deaths report

On 21st March 2023 I commenced an investigation into the death of Terence Briney. The investigation concluded on the 8th December 2023 and the conclusion was one of Natural Causes. The medical cause of death was 1a) Acute respiratory event on the background of an aspiration 1b) Frailty II) Myocardial Infarction, Ischaemic Heart disease and Aortic Stenosis

Terence Briney's health began to deteriorate significantly from July 2022. His appetite reduced, he had increasing lethargy and developed tremors. He began to lose weight. No investigations were carried out until he was referred to gastroenterology on the cancer pathway. He was very frail by the time of the referral. The tests indicated his oesophagus was not functioning effectively but there was no clear cause. He was admitted to Stepping Hill Hospital on 15th March 2023 after the GP examined him and was concerned about how frail he was. On admission no clear reversible cause was identified. He was put on Nil by Mouth due to his poor oesophageal functionality. He presented a high risk of aspiration. On the balance of probabilities, the deterioration in his oesophageal function was due to an undiagnosed neurological condition. On 17th March he suffered an acute respiratory event due to aspirating on his saliva. He died at Stepping Hill Hospital on 17th March as a consequence.

The inquest heard evidence that symptoms raised by Mr Briney and his family were attributed to old age rather than a possible neurological disease. The evidence before the inquest was that there were situations where clinicians would attribute a deterioration to the aging process rather than consider the whole picture and investigate if there was a treatable condition. This presented a risk that treatable conditions in the elderly could be missed.