On 23rd December 2014, commenced an investigation into the death of June Elsie Parkes aged 68 years_ Date of birth 13.06.1946. The investigation concluded at the end of the inquest on 27th January 2016_ The conclusion of the inquest was that June Elsie Parkes died at 02.00 hours on 17 December 2014 at Huddersfield Royal Infirmary, shortly after transfer from Calderdale Royal Hospital, as a result of a massive upper gastrointestinal haemorrhage caused by a bleeding duodenal ulcer_ Mrs Parkes initially became unwell on the morning of 14 December 2014 and was reviewed by an out of hours general practitioner . At the time she was not admitted to hospital: It is likely that if she had been and treated she would not have died at 02.00 hours on 17 December 2014 She was admitted to Calderdale Royal Hospital shortly before midnight on 14 December 2014 due to a further deterioration in her condition; She was subsequently diagnosed with non-bleeding deep duodenal ulcer_ Mrs Parkes had been transferred to Huddersfield Royal Infirmary for ongoing investigations and treatment on or before the afternoon of 16 December 2014,it is likely that her death at 02.00 hours on 17 December 2014 would have been avoided.

Mrs Parkes became unwell at home on Sunday 14th December 2014 and was admitted to Calderdale Royal Hospital shortly before midnight with history that of being clammy, suffering abdominal pain, passing dark stools and low blood pressure_ Immediately before admission she had suffered a sudden collapse, followed by episodes of vomiting dark fluid with the appearance of fresh blood present. Upon admission she was found to be unstable and in a state of clinical shock. working diagnosis of an upper gastro intestinal bleed was made. Resuscitation treatment was implemented with the plan that if Mrs Parkes condition stabilised, she would undergo an urgent endoscopy: Her condition did improve and a written request was hand delivered to the endoscopy department for an urgent endoscopy to be_performed day

Subsequently at 9.OOam her condition deteriorated, Mrs Parkes was reviewed by critical care outreach sister who considered that Mrs Parkes required an emergency endoscopy and she should be transferred to Huddersfield Royal Infirmary. Mrs Parkes was subsequently reviewed by a consultant who thought transfer may result in a delay in the endoscopy performed, and received reassurances that Mrs Parkes would be placed first on the afternoon list to undergo an endoscopy_ heard evidence at the inquest that at Calderdale Royal Hospital, endoscopies are performed in either morning or afternoon list, Monday to Friday, with urgent or emergency endoscopies fitted in where possible. This was dependant on, subject to, appropriately qualified staff being available and that such staff that were qualified did not have "ring fenced" Iist, which would mean no urgent or emergency endoscopies could be added to their list was advised that staff suitably qualified on the morning of the 15th December did have ring fenced list: Although, this didn't appear to be communicated to Mrs Parkes consultant: also heard evidence that there was no facility to undertake out of hours endoscopies_ or at weekends O , surgical intervention for upper gastro intestinal bleeds at Calderdale Royal Hospital Patients would require to be transferred to Huddersfield Royal Infirmary for these procedures In addition, in the afternoon of the 15th December; bloods had not been ordered by her treating clinicians which were required before Mrs Parkes transfer for endoscopy: Mrs Parkes underwent her endoscopy at 16.45 hrs, she found it very difficult to tolerate_ No active bleeding site was identified, but it was noted that she had deep ulcer with evidence of previous bleeding: The Endoscopist was unable to proceed further with the examination. She recommended medication and that in the event of a further bleed Mrs Parkes should undergo further examination under deep sedation, or, a CT angiography: Both of which would require to be undertaken at Huddersfield Royal Infirmary: At 22.00 hrs that evening Mrs Parkes suffered an episode of melaena_ No doctor was requested to review Mrs Parkes Mrs Parkes observations were not checked monitored The next observations were undertaken at 8.00am the following morning; now 16th December: The following morning Mrs Parkes was reviewed in a consultant led ward round, no blood tests were requested_ Mrs Parkes experienced a further episode of melaena at 2.30 that afternoon. Shortly afterwards Mrs Parkes was reviewed by a critical care outreach sister who requested blood tests and senior doctor review: Blood test results reviewed by a senior house officer, two hours later revealed reduced haemoglobin levels These were verbally discussed with a consultant who recommended that Mrs Parkes should receive a further blood transfusion, and that if there was any further deterioration in Mrs Parkes condition overnight;, she should undergo an emergency endoscopy: Otherwise, she should undergo an endoscopy the following morning: No arrangements were put in place for Mrs Parkes transfer to Huddersfield Royal Infirmary: Mrs Parkes vital signs remained stable throughout this period. At 20.30 Mrs Parkes became dizzy: Her condition rapidly deteriorated. She had recordable blood pressure; she passed significant amounts of melaena and vomited fresh blood_ Mrs Parkes was reviewed and supported by number of doctors and nurses including an intensive care consultant; who gave evidence that he expected that Mrs Parkes to be transferred at 23.00 hours although she was still gravely ill However_ at the inquest it was difficult to establish the precise sequence of events, and it was not possible to establish why Mrs Parkes was not transferred to Huddersfield Royal Infirmary until 1.25hrs nOw the 7th December_ being and

Mrs Parkes was transferred by ambulance with nurse in attendance. Mrs Parkes arrived at Huddersfield Royal Infirmary at 1.45 hours and transferred to the surgical assessment unit She was immediately assessed and sadly found to be unresponsive and her death was confirmed a short time later.