Geoffrey Robin Brooks · Prevention of Future Deaths report

On 10 November 2020 an investigation was commenced into the death of Geoffrey Robin Brooks. The investigation concluded at the end of the inquest held on 14 September 2023. The conclusion of the inquest was as follows:

Geoffrey Robin Brooks died due to complications of nephrogenic diabetes insipidus on a background of poor fluid intake.

Geoffrey Robin Brooks suffered with nephrogenic diabetes insipidus diagnosed in 2013. In 2020 Mr Brooks’s health declined and he had multiple admissions to hospital. In August 2020 he was admitted to the Exmouth Community Hospital. Due to his diabetes insipidus Mr Brooks required monitoring of his blood sodium to ensure that he was maintaining the correct balance of fluid intake to remain stable. On admission his blood sodium was low, and he was on a restricted fluid intake; during his admission his condition improved, and he was moved from a restricted fluid intake to a daily target level of fluid intake of 2.5 to 3L per day. On 25 September 2020 Mr Brooks was discharged to the Barton Place Nursing Home. The discharge summary did not clearly set out Mr Brooks’s fluid requirements and the nursing home staff believed Mr Brooks was to be restricted to no more than 2.5 -3L per day rather than that figure being a target to aim for; the nursing home were advised it was a target on 9 October 2020 after Mr Brooks became unwell; the target level of 2.5 to 3L was not achieved during his stay in the nursing home. On 18 October 2020 Mr Brooks’ health deteriorated and was admitted to hospital where despite treatment he sadly died on 12 November 2020.

(1) During his evidence the consultant physician with the responsibility for the care and treatment of Mr Brooks acknowledged that the discharge summary was ambiguous and did not make it clear that the 2.5 – 3L was a target fluid intake; he agreed that it could be interpreted that Mr Brooks should be restricted to no more than 2.5 to 3L of fluid a day. As a consequence, the nursing home staff were unaware of the needs of Mr Brooks. The target fluid intake was not met in the period that Mr Brooks was in the nursing home, which contributed to his death.