On 3 July 2015, commenced an investigation into the death of Darren Jones, aged 42_ The investigation concluded at the end of the inquest on 19 November 2015. The conclusion of the inquest was natural causes The cause of death was 1a Massive left sided pleural and mediastinal haemorrhage_ 1b Perforation of the thoracic aorta_ Ic Invasive aspergillosis_ 2 Chronic kidney disease with renal transplant Iheard from several witnesses atinguest The Burton witnesses were ocum consultant physician, and locum consultant physician: reau InerStalement Iconsultant cardiolgist; onto the record:

Events leading to final admission Darren Jones was born on 15.11.72. His PMH included CKD, ankylosing spondylitis and a type of muscular dystrophy: He had a kidney transplant in 2009. He needed immunosuppressant medication after his transplant. We heard that Mr Jones started to show signs of organ rejection in late 2014. The evidence of Mr Jones' consultant nephrologist Ifrom Nottingham University Hospitals NHS Trust was that this may have been caused by the prescription of Adalimumab by rheumatologists at Burton earlier that year. She could not say that this was the most likely cause. The organ rejection may have been caused by several other factors. Mr Jones was admitted to hospital in December 2014 and treated for a Cryptosporidium infectionAfter that admission,he was seen by_his GP and at the understand plan that he would only consult Mr Jones' renal team when re-starting the medication levidence was that;, if she had been consulted, she would have advised that the medication should not be stopped I requested a copy of the trust's protocol and that of the Nottingham trust; to look specifically at what guidance there is to doctors at Burton on when to contact patients' renal teams. The protocol provided to me for Burton appears limited in that referral is only mandated where there is AKI stage 3, and no improvement after 24 hours of fluids The protocol does not deal with transplant patients.
2. Availability of immunosuppressant medication was advised at the inquest that the medication can now be obtained more quickly than within 24 hours. was not given more specific information about this_ and the experience of Dr Rabbani on 9 March was that the would take 24 hours to arrive_ be grateful if you would consider the following points arising out of this inquest A review of current protocols regarding when renal advice should be sought for patients particularly those who have undergone transplants_ appreciate that the usual renal team for patients in Burton would be based in Derby. Education and sharing of new protocols that are created, to all relevant staff. Availability of immunosuppressant drugs at short notice

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: