James Flynn
PFD Report
Historic (No Identified Response)
Ref: 2016-0390
Coroner's Concerns (AI summary)
Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.
View full coroner's concerns
(1) That an elderly patient who was still very unwell was discharged home very late in the evening without a detailed care plan being in place, His immediate family were unaware of the discharge and there was no food or provision for him in the house despite being a type 2 diabetic.
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
(2) Inadequate planning and management of patient discharge will put patients lives at risk.
HM Coroners Office, Civic Offices, 1 Saxon Gate East, Central Milton Keynes, MK9 3EJ Tel 01908 254326 | Fax 01908 253636
Sent To
- Oxford University Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
26 Dec 2016
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14th December 2015 I commenced an investigation into the death of James Francis Flynn,
68. The investigation concluded at the end of the inquest on 25th October 2016. The conclusion of the inquest was a narrative conclusion as attached.
68. The investigation concluded at the end of the inquest on 25th October 2016. The conclusion of the inquest was a narrative conclusion as attached.
Circumstances of the Death
The deceased suffered from Chronic Pancreatitis. He was last seen by his GP on 12th November 2015 with acute pancreatitis and was admitted to Milton Keynes Hospital. Mr Flynn was later referred on to the John Radcliffe Hospital where he was treated. He was discharged home on the 8th December 2015 arriving at 2058 in the evening. At 1715 on 9th December his family attended but could not gain access to the house, they went to the rear of the property and saw Mr Flynn knelt face down on the floor of his ground floor bedroom. The police forced entry and Mr Flynn was found unresponsive; CPR was commenced until the paramedic confirmed death at 1806.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.