On the 27th of January 2016 I commenced an investigation into the death of David Aughton aged 63 years: The investigation concluded at the end of the Inquest which was concluded on the 11t May 2016. The conclusion of the Inquest was that David Aughton had died from an Accidental Death_

In August 1999 David Aughton fell and sustained a severe traumatic brain injury which led to epileptic seizures: Those seizures were controlled by lamotrigine and sodium valproate: On the 21s December 2015 he was admitted to the Royal Blackburn Hospital for cystoscopy which was performed under general anaesthetic; Whilst at the Royal Blackburn Hospital he had not been administered his anticonvulsant medication such that on the 22nd December 2015 he had a grand mal convulsion which caused aspiration pneumonia. Thereafter he remained unwell until he died on the 25t January 2016.

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: YouR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 7th July 2016. 1, the Coroner, may extend this period, Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action proposed