On 31st March 2015 I commenced an Investigation into the death of Brian Anthony Gillard, 79 years, born 12t June 1935. The Investigation concluded at the end of the Inquest on 11t June 2015, The medical cause of death was 1a) Congestive cardiac failure, 1b) Asbestosis: The conclusion of the inquest was Industrial Disease_

1, Brian Anthony Gillard died at the Royal Bolton Hospital, Minerva Road, Farnworth, Bolton on the 20t March 2015.
2. Mr Gillard had been exposed to asbestos during his working life at various locations and at various times between 1951 and 1999 when he worked as a Pipe Lagger. In 2014 Mr Gillard presented to the Respiratory Service at the Royal Bolton Hospital, Bolton with a six month history of rapidly progressive breathlessness and subsequently, he was diagnosed as suffering with Asbestosis. He was treated on Oxygen at home September 2014 after seeing a Consultant Respiratory Physician at the Hospital and he was reviewed on a monthly basis by various Respiratory Nurses with regard to his Oxygen requirements: 3_ On the 28th February 2015 Mr Gillard was admitted to the Royal Bolton Hospital, Bolton with a history of recurrent collapses and by this time he was known to be on long term Oxygen therapy for breathlessness due to Pulmonary Fibrosis: During his time in Hospital Mr Gillard was noted to have _increased Oxygen requirements and the Respiratory_Nurses _ July from arranged for him to have increased Ambulatory Oxygen at home, which was delivered to his home address at the time of his discharge on the 14th March 2015. 4, On the 18* March 2015 at 17.20 hours Mr Gillard attended the Emergency Department of Roval Bolton Hospital, Bolton by ambulance and it was known that he had a past medical history of Asbestosis and he was on long term Oxygen therapy; He presented to the Hospital with increased shortness of breath, low Oxygen saturations and poor mobility. The Respiratory Nurses had seen him in the community and the Nurses advised his admission to the Hospital; After preliminary investigations he was treated for pneumonia pending a chest X-ray and the chest X-ray showed increased right sided congestion: He was using Oxygen during transfer from his home address to the Hospital in the ambulance and he continued to use Oxygen in the Emergency Department at the Hospital_ He was known to require Ambulatory Oxygen from the Hospital notes in relation to his previous admission and at the time of his admission to the Emergency Department at the Hospital: Mr Glllard had arrlved at the Emergency Department at the Hospltal at 17.20 hours on the 18t March 2015 and later that evening he was transferred from the Emergency Department to D1 Ward at the Hospital.
6. Mr Gillard was taken to D1 Ward by a Hospital Porter and he was received on D1 Ward by who is an Assistant Practitioner _ gave evidence at the Inquest that he did not receive a formal handover from the Emergency Department and he was not aware that Mr Gillard required Ambulatory Oxygen: also gave evidence that there was no system in place at the Hospital in relation to handover from the Emergency Department to the Ward, particularly in relation to Oxygen requirements: At approximately 05.30 hours on the 19th March 2015 Mr Gillard was in bed when he requested the tollet and he was offered a commode next to his bed, However , Mr Gillard insisted that he be taken to the toilet andl took him to toilet in a wheelchair without continuing Oxygen: accepted that portable Oxygen supply was available for use between the Hospital bed and the toilet but Mr Gillard was happy to go to the toilet without Oxygen and was not aware that Mr Gillard required Ambulatory Oxygen:
8. When Mr Gillard was taken to the toilet he was left in the tollet, which did not have an Emergency pull-cord, for privacy and_ Ireturned to his duties for three to four minutes leaving Mr Gillard in the toilet on his own: When returned to the toilet approximately four minutes later he found Mr Gillard collapsed behind the toilet door and Mr Gillard had the the suffered a cardiac arrest believed to be due to Hypoxia: Mr Gillard was resuscitated and he was transferred to his bed; A repeat chest X-ray showed worsening congestion and subsequent dlinical assessment revealed a raised JVP and bilateral chest crepitations Mr Gillard was treated with intravenous diuretics, intravenous antibiotics and increased oxygen support but on the 20* March 2015 he deteriorated and died.