On the 22nd May 2017 | commenced an investigation into the death of Robert Andrew Power The investigation concluded at the end of the inquest on the 4ih May 2018. The conclusion of the inquest was natural causes_ The medical cause of death was 1A Bronchopneumonia and urinary tract infection, 1B Multiple Sclerosis_

Robert Andrew Power 'Robert" was a 49 year old man who lived in a care home specialising in neurological conditions He had history of significant and alcohol abuse In 2007 he suffered a marked change in his physical abilities and he underwent extensive investigations_ He was diagnosed with gliomatosis cerebri, and discharged to terminal care home_ This diagnosis was incorrect. In 2014 his GP requested further assessment of Robert Neurological opinion was sought; and it was determined that Robert had suffered significant damage to his brain, and had a chronic undefined inflammatory condition affecting his brain In July 2015 Robert was admitted to a care home specialising in neurological management Thereafter whilst Robert's condition remained relatively stable, he was admitted to hospital on multiple occasions suffering with aspiration pneumonia, and or seizure activity. Following ongoing deterioration_ and after discussion with his family, it was agreed there would be no further escalation of treatment in the event of further deterioration On the 12th April 2017 Robert was admitted to hospital suffering with aspiration pneumonia: He was discharged on the 4"h 2017 for palliative care His condition steadily deteriorated. He was regularly reviewed by his GP. Robert passed away on the 17th 2017 . During the course of the inquest the evidence revealed a matter giving rise t0 concern_ The MATTER OF CONCERN was as follows Robert whilst treated as a patient by the trust was essentially lost to follow up between 2007 2015 No explanation was given as to why this happened For the reasons given in my summary of evidence | determined that there was no evidence that this area of concern had any direct causative impact on Robert's death_ However in my opinion there is a risk that future deaths may occur unless action is taken to ensure that outpatients are not lost to follow Up care It is acknowledged that significant steps have already been made