On the 22 August 2016 I commenced an investigation into the death of the late Mr Vinod Kumar. The investigation concluded at the end of the inquest on 12 October 2016. The conclusion of the inquest was a short narrative conclusion of accidental death. The cause of death was la Multi Organ Failure b Group A Streptococcus Septic Shock c Necrotising Fasciitis secondary to laceration sustained from fall + RCUMSTANCES OF THE DEATH I) Mr Kumar was a very active and healthy family man who attended the gym and kept fit. O r aro rd the / gust 2016 he was orplai g of fecli ig urwe with flu ike sy pt ‘ns Urusua I for t r this esulted tak og time of work The following day he had a fail at home and sustaned a graze to his rght arm elbow. Hs codton ccntimjec m dece and e attended Ne Cross H al Cv g 9 A t 2 afre Viu see n o a o a r r ed v a d e in t’e Accdent ann Emergency Department he was ntiallv seen b a Triage nurse who categorsed him a eve 4 (ieast urgent and to K h s ha o y n d g f and a o len/p irful a v He ae arar at rig , a I to a ar 9 c”i t a a se c was extremely l and in muftorqanfaure vii) His condition declined further and sepsis secondary to necrotising fasciitis was dag nosed vni) Despite surgical intervention to remove the infected tissue he died shortly after the surgery on the 10 August 2016 ix On the balance of probability the likely source of necrotisi g fasciitis was the graze on the arm injury

1. You may wish to consider reviewing your polcy!guideIines in respect of the current sepsis policy, particularly in light of what happened to Mr Kumar. Evidence of swelling to his arms and the history given may have triggered an earlie blood tcst and observations YOUR RESPONSE You are under a duty o respono to th s rport within e days of the date of tf is eport na e by c b o c o ay
x. d e r r5pr9c must nar deta 0’ actn akr or proposed o ak settn a oO rsco ue a v racon no cc COPIES and PUBLICATION l have sent a cony of m report to the Chef Corone and to the fciowng lnteresred Person rvirs Kmar [iL