On 30th October 2013 commenced an investigation into the death of Anne Whitworth aged seventy-eight; The investigation concluded at the end of the inquest on 4" July 2014. The conclusion of the inquest was Anne Whitworth was a widowed lady aged seventy-eight years who had suffered with diarrhoea for two weeks. She saw her GP on 30th August 2013 oegarding ' who arranged for her to see a gastroenterologist for further investigations. By September 2013, Whitworth was now 'suffering with constipation. She saw a doctor at the Local Care Direct Drop-In Centre when it was thought that she was constipated and a laxative was prescribed, Whitworth became acutely unwell later that day and was taken to St James s University Hospital, Leeds by ambulance where her death was confirmed at 2205 hours on 8" September 2013. post mortem examination reveals the cause of her Intestinal Obstruction was a Volvulus of the Sigmoid Colon which was not identified at her previous GP and emergency appointment: concluded that this to be a death from natural causes_

Mrs Whitworth had seen her own GP o 30th August 2013 complaining of a two week history of diarrhoea Her GP was concerned about her symptoms and arranged a referral to a gastroenterologist for further investigation This referral had not been achieved by the date of death_ Mrs Whitworth developed severe stomach pains and shortness of breath on Or around 8th September 2013. She was taken by her son to a Local "Drop-In Doctor" and the attending doctor diagnosed a blockage in her bowel and prescribed medication and advised her to see_her GP if her symptoms did not this, Mrs Mrs resolve Later that her pain became considerably worse. An ambulance was called and Mrs Whitworth was taken to St Jamess University Hospital, Leeds at 2130 hours on 8 September 2013. Whitworth suffered a respiratory and cardiac arrest on route to hospital. Despite all efforts, her death was confirmed at 2205 hours on 8h September 2013. A post mortem examination showed the cause of death to be 1(a) Aspiration of Gastric Contents due to (b) Intestinal Obstruction due to (c) Volvulus of Sigmoid Colon

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action, That Local Care Direct organisation should urgently explore and investigate the possibility of implementing compatible computer systems with GP practices and Doctors operating out of hours consultations in "Drop-In Centres" so that GPs who see the patients Of others often in an emergency when such patients are vulnerable and who might be poor historians and have limited communication skills may not adequately be able to explain their recent medical