On the 9th April 2013 the coroner for Birmingham commenced an investigation into the death of KEWARD GUY DOMONIC HARDING aged 27 at Queen Elizabeth Hospital. Jurisdiction was passed to me on the 18th June 2013 and the investigation concluded at the end of an inquest held at Dorchester on the 15th August 2013. conclusion of the inquest was that he had died of natural causes with the medical cause of death being la) Multiple organ failure, Ib) Dilated cardiomyopathy, Ic) Sepsis (treated) Obesity Type III Diabetes Mellitus_ Diverticulitis and Infected Cellulitis

Mr Harding had a learning disability and lived at home with his mother: He was seen by IGP on the 12th and 1gh March 2013. On the second occasion he did not exhibit signs Of serious physical illness bulb felt that a mental health assessment should be carried out urgently: She telephoned to discuss her concerns and to request an urgent referral and followed this up with a letter dated 20"h March 2013 advised that an assessment would be carried out in days. It would appear that Mr Harding deteriorated over the Easter weekend and kalled The Bridges Medical Centre on Tuesday 2" April to express her concern about her son: ivisited the family home that to find Mr Harding hypoxic, hypotensive and oedematous with suspected sepsis. Mr Harding was admitted to Dorset County Hospital critically unwell and was later transferred to Birmingham on the 6lh April for consideration of extra-corporial assistance and possible heart transplantation but he sadly died on the 7E April The day

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