On the 30"h May 2012 commenced an investigation into the death of Keith Thomas Graham aged 45 years_ The investigation concluded at the end of the inquest on the 29"h November 2013. Cause of death Multiple Injuries_ On the 22nd' May 2012 the deceased Ieft a public house in Burgh by Sands on his motor having consumed three pints of beer. He travelled along the c.2042 road at high speed when he was in collision with a bullock was transported to the Cumberland Infirmary, Carlisle where he underwent surgery, dying from his injuries on the 28lh The conclusion of the inquest was Road Traffic Collision.

The deceased was involved in a Road Traffic Collision He reached the Cumberland Infirmary, Carlisle at 20.08 hours He was in a poor condition. It was planned that he be taken to a CT Scanner which occurred at 21.20 hours_ He was suffering from Hypotension and was taken to Theatre at 21.30 hours. The on call Consultant was not contacted until 21.15 hours_ A chest drain was misplaced and caused damage to the liver . He underwent a Throacotomy and three Laparotomies in the space of some 5 Vz hours. The consensus of medical evidence was that on the balance of probabilities he would have died of his injuries in any event,

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. you ANDIOR