On 29th January 2013 I commenced an investigation into the death of James Hadfield Withers (dob 16/8/26).The investigation concluded at the end of the inquest on 19th September 2013. The conclusion of the inquest was “In October 2012 Mr Withers was diagnosed as suffering a recurrence of carcinoma of the bowel. He was admitted to hospital for a resection of the affected area on the 11th December 2012: Immediately post operatively he was treated on the ITU and made very good progress. He was then transferred to the surgical ward and his condition generally deteriorated thereafter: During his time on this ward and after his return to the ITU there were a number of occasions of poor communication with the family of the deceased; he was thought to be classified as DNAR when a doctor mistook him for another patient; little or no explanation was given to the family as to his actual DNAR status and/or as to why it was deemed appropriate as to why and when it was decided to take him off ventilation. On the 27th January 2013 he died as a result of his diseased heart, contributed to by the stress of the necessary operation to remove the cancer” The medical cause of death was 1a Congestive Cardiac failure 1b left ventricular failure 1c valvular heart disease (aortic stenosis) 2. Open extended right hemi-colectomy for invasive colonic adenocarcinoma .

The circumstances are apparent from the conclusion as outlined above