UK Inquiry Tracker

Andrew John Fallon

PFD Report Historic (No Identified Response) Ref: 2014-0005

Date of Report 7 January 2014

Coroner John Pollard

Coroner Area Manchester (South)

Response Deadline ✓ from report 4 March 2014

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.

View full coroner's concerns

In circumstances it is my statutory duty to report to you: heard evidence from the medical staff and others that the staffing levels within the Emergency Department were such that the doctors simply could not cope with the volume of work, thus leading to inordinate delays in treating the patients_ was specifically informed that there were, as is frequently the case, numerous patients at the Emergency Department with what can only be described as minor or trivial complaints. It appeared to me during the course of the evidence that a effective solution/help would be for there to be a Primary care facility staffed by GP's within or immediately adjacent to the ED. This would enable the triage nurse to allocate those minor conditions to_the Primary_care_facility_This would then being day and the The very mean that those patients such as Andrew Fallon with severe health issues would not be kept waiting so long for treatment.

Sent To

Stockton NHS Foundation Trust

Response Status

Linked responses 0 of 1

56-Day Deadline 4 Mar 2014

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 26th November 2012 commenced an investigation into the death of Andrew John Fallon born on the 18th June 1977 . The investigation concluded at the end of the inquest on 23rd October 2013. The conclusion of the inquest was that he died from natural causes, the medical cause of death 1a bronchopneumonia 1b post resuscitation of cardiac arrest 1c hypokalaemia due to gastroenteritis and Part 11 Becker's muscular dystrophy:

Circumstances of the Death

On the 9th November 2012 he was admitted to Stepping Hill Hospital with a history of four days vomiting and abdominal pain and was diagnosed as having gastroenteritis Later that same he suffered a cardiac arrest and although he was resuscitated he was left with severe neurological damage and needed full support on the ITU: He showed no improvement ventilator support was withdrawn and he died on the 15th November.

Action Should Be Taken

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