Coroner's Conclusions

Cause of death: 1a) Anaphylactic shock due to teicoplanin
Conclusion: Misadventure  

Cause of death: 1a) Respiratory failure 1b) Pneumonia 1c) Fall and rib fractures 2) Frailty of Old Age 
Conclusion: Accident 

Cause of death: Ischaemic colitis 2) Subarachnoid Haemorrhage
Conclusion: Narrative Conclusion - Terence Michael MCCORMICK sadly died on 29/10/2024 at Whiston Hospital Merseyside. Terence was admitted to hospital on 24/10/2024 after experiencing an unresponsive episode, he also collapsed. Terence had a number of serious underlying clinical co-morbidities.

A CT head scan was performed which demonstrated a likely traumatic haemorrhage which contributed to the natural cause of death of Terence.  

Cause of death: 1a) Head injury
Conclusion: Accident  

Cause of death: 1a) Hanging 2) Illicit Drug Use / Dependence
Conclusion: Suicide  

Cause of death: 1a) Mixed Drug Toxicity 2) Myocardial fibrosis
Conclusion: Drug related  

Cause of death: 1a) Mixed drug toxicity and aspiration pneumonia 2) Ischaemic Heart Disease, Fatty Liver Disease
Conclusion: Suicide 

Cause of death: 1a) End stage renal failure and infected hip wound 1b) Ischaemic and diabetic nephropathy and prosthetic fracture (operated) 1c) Ischaemic heart disease, Diabetes and Fall
Conclusion: Narrative Conclusion - Edward Henry MCARDLE sadly died on 25/10/2024 at St Joseph's Hospice Ince Road Liverpool.

Edward who had a number of serious underlying clinical co-morbidities also suffered a fall which resulted in a prosthetic fracture. Edward was admitted to hospital on 15/09/2024 and he underwent surgery the following day. Edward did not have the physiological reserve to recover from the fall and subsequent surgery, his condition deteriorated and palliative care was commenced. Edward subsequently passed away peacefully in receipt of end of life care.

Cause of death: 1a) Metastatic adenocarcinoma of the stomach 2) Fractured left neck of femur
Conclusion: Narrative Conclusion - Patricia Lloyd sadly died on 20/11/2023 at Halcyon House Care Home, 55 Cable Street, Formby, Merseyside L37 3LU.

Patricia had serious underlying clinical disease which caused her death (Metastatic adeno carcinoma of the stomach), Patricia also had pre-existing acute kidney injury and functional decline. The occurrence of a hip fracture which occurred when Patricia fell/collapsed in her care home, compounded by the subsequent surgical procedure was a contributory factor in the cause of her death.

On the early morning of 09/11/2023 (~0100hours) Patricia was discovered on the floor in her room by a Registered Nurse. Patricia told the nurse that her leg hurt and that she needed to go to the toilet.

Patricia was restless and she was trying to move her legs. The registered nurse believed Patricia may have fractured her leg or her pubic ramus. The nurse in charge, accompanied by two care assistants, manoeuvred Patricia safely to her bed. Patricia was also a diabetic and her blood sugar was low, consequently she was given some jelly babies to raise her blood sugar. Patricia initially declined analgesia and she had capacity to do so.

The Nurse initially called 111 and spoke with a doctor, expressing her concerns about Patricia having sustained a fracture. An ambulance was also subsequently called (999) and it arrived at about 08.00 hours and Patricia was taken to hospital. Patricia was admitted to hospital at ~08.42, she underwent surgery for a fracture to her hip on 10/11/2023.

Patricia was discharged from hospital on 17/11/2023 for best supportive care. A DNAR Order had been in place since ~2022, a CT scan of the thorax, abdomen and pelvis on 16/11/23 showed liver metastases, lung nodules, mild ascites, bilateral pleural effusions with collapse of lung parenchyma.

On balance, lifting Patricia from the uncarpeted floor to her bed for safety reasons i.e. to prevent any complications and to provide a greater degree of comfort and warmth did not cause or contribute to the death of Patricia.

Cause of death: 1a) Pelvic sepsis 1b) Infected mesh 1c) Sacrospinous fixation with mesh 2) Chronic Obstructive Pulmonary Disease, Congestive Cardiac Failure
Conclusion: Misadventure

Cause of death: 1a) Pneumonia 1b) Left neck of femur fracture 1c) Fall 2) Dementia, Type 2 Diabetes, Frailty
Conclusion: Misadventure

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Traumatic acute subarachnoid haemorrhage, bilateral intracranial haemorrhage 1c) Fall 2) Lewy body dementia
Conclusion: Misadventure

Cause of death: 1a) Lower respiratory tract infection 1b) Traumatic Subdural Haematoma 2) Alzheimer's Dementia
Conclusion: Misadventure

Cause of death: 1a) Haemoperitoneum 1b) Cholecystomy 1c) Cholecystitis with Empyema 2) Ischaemic and valvular heart disease
Conclusion: Narrative Conclusion - Mr Rickards died at Whiston Hospital on 29th November 2023 from bleeding into the Peritoneal Cavity and also into the Fibrinous Cystic Cavity around the site of a Cholecystostomy procedure which had been performed at Whiston Hospital on 10th November 2023. Bleeding within the Peritoneal cavity is a known and recognised complication of Cholecystostomy surgery. The amount of blood loss suffered by Mr Rickards was a catastrophic event resulting in: hypovolaemic shock leading to multi-organ failure and subsequent death

Cause of death: 1a) Neck of Femur Fracture 1b) Fall
Conclusion: Misadventure

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Extreme Prematurity 1b) Medical termination of pregnancy 1c) Severe congenital abnormalities of the central nervous system
Conclusion: Narrative Conclusion - Baby Ava was born extremely prematurely albeit following a termination of Pregnancy having been undergone by her mother. Due to severe congenital abnormalities life was not viable and Baby Ava died at 1515hrs on 20th March 2024 at Whiston Hospital.

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Frailty 1c) Metastatic Malignant Melanoma 2) Fractured Neck of Femur (Operated)
Conclusion: Misadventure

Cause of death: 1a) Alcoholic Ketoacidosis and Acute Alcohol Toxicity 2) alcohol-related liver disease
Conclusion: Alcohol related

Cause of death: 1a) Combined Ethanol and Morphine Toxicity 2) Alcoholic Fatty Liver, Bronchopneumonia
Conclusion: Alcohol and Drug related

Cause of death: 1a) Odontoid peg fracture 1b) Fall, Frailty
Conclusion: Misadventure

Cause of death: 1a) Cardiac Event 1b) Left Hip Fracture 1c) Fall 2) Advanced age, Alzheimer's  
Conclusion: Misadventure

Cause of death: 1a) Pneumonia 1b) Right Hip Fracture 1c) Fall
Conclusion: Misadventure

Cause of death: 1a) Cocaine Toxicity
Conclusion: Drug related

Cause of death: 1a) Heart failure 2) Atrial fibrillation on apixaban, Metastatic Prostate Cancer, Right neck of femur fracture due to accidental fall 
Conclusion: Misadventure

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Fractured Right Neck of Femur 2) Ischaemic heart disease 
Conclusion: Misadventure

Cause of death: 1a) Mixed Dementia 2) Neck of femur fracture (treated), Frailty 
Conclusion: Misadventure

Cause of death: 1a) Peritonitis 1b) wound breakdown 1c) colorectal adenocarcinoma (Operated) 2) Peripheral vascular disease
Conclusion: Narrative conclusion - On 9th November 2023, Mrs Murray died at Aintree Hospital from Faecal Peritonitis which was caused by wound breakdown in the Bowel wall opposite to an anastomosis following a right hemicolectomy procedure which had been performed at Southport Hospital on 30th October 2023. The wound breakdown is a known and recognised surgical complication which can occur at the site of an anastomosis or in the adjacent area thereto.

Cause of death: 1a) Multiorgan Failure 1b) Severe bradycardia with heart failure 1c) Beta blocker toxicity with acute kidney injury secondary to hypovolaemia following diarrhoeal illness 2) Chronic obstructive airways disease   
Conclusion: Natural causes

Cause of death: 1a) Exacerbation of chronic obstructive pulmonary disease 2) The Toxic Effects of Morphine
Conclusion: Narrative Conclusion - Alan Jackson sadly died on 29/08/2024 at 6 Franton Walk Liverpool L32 0SS. Alan died from an exacerbation of his chronic lung disease but it was also possibly contributed to by the use of morphine/ heroin at some time prior to his death. There were no suspicious circumstances surrounding his death.

Cause of death: 1a) Unascertained
Conclusion: Narrative Conclusion - James Dennis OWEN was sadly found deceased on 16/09/2024 at 80 Ashurst Drive St Helens WA11 9DW. James had a medical history of chronic pain, anxiety and mood disorder, he had not been seen for about 3 days when he was subsequently found deceased on his bed. Police were satisfied there was no third party involvement in James death. The pathologist conducted a post mortem examination, however, he could not establish a cause of death but in the absence of any toxicological findings he concluded the death of James was undetermined but likely to be natural.

Cause of death: 1a) Toxic effects of Venlafaxine
Conclusion: Drug related

Cause of death: 1a) Pneumonia 2) Congestive Cardiac Failure, Fall, Subdural Haematoma, Type II Diabetes Mellitus, Frailty, Dementia.
Conclusion: Narrative Conclusion - Margaret MASON sadly died on 05/10/2024 at Whiston Hospital Merseyside L35 5DR, Margaret was admitted to hospital on 24/08/2024 after having fallen against a radiator, a CT head scan demonstrated Margaret had sustained a subdural haematoma. Margaret underwent neurosurgery at the regional centre after which she returned to the general hospital, where not withstanding all appropriate care and treatment her condition deteriorated, culminating in her death.

Cause of death: 1a) Acute Ischaemic Stroke 1b) Cerebral and Carotid Artery Thrombosis 1c) Cocaine Abuse
Conclusion: Drug related

Cause of death: 1a) Traumatic subarachnoid haemorrhage 1b) Fall 2) Frailty of age
Conclusion: Accident 

Cause of death: 1a) Congestive heart failure 2) Frailty, Chronic kidney disease, Fall, Fracture neck of femur, infection of unknown source
Conclusion: Narrative Conclusion - Jean PURCELL sadly died on 06/10/2024 at Whiston Hospital Merseyside L35 5DR. Jean had a number of significant medical conditions that contributed to her death. Including a fracture sustained to her hip following a fall at her home, but her death was due to heart failure. As Jean's condition deteriorated, she was commenced on end of life care to enable her to die in peace, pain free and with dignity. Jean subsequently died peacefully on the ward.

Cause of death: 1a) Cocaine Toxicity 
Conclusion: Drug related

Cause of death: 1a) Combined drug toxicity 1b) Chronic Obstructive Pulmonary Disease
Conclusion: Drug related

Cause of death: 1a) Tetanus 2) Severe Frailty 
Conclusion: Narrative Conclusion - Mr James died on 23rd August 2024 at Whiston Hospital as a result of tetanus infection. On 17th August 2024 Mr James had sustained an injury gardening in which a rusty nail punctured his lower left leg.

Cause of death: 1a) Group A strep bacteraemia 2) Rheumatoid arthritis, Substance misuse
Conclusion: Natural causes

Cause of death: 1a) Brain haemorrhage 1b) Fall 2) Frailty, Thrombocytopenia, Crohn's Disease, Dementia 
Conclusion: Misadventure

Cause of death: 1a) Head Injuries 1b) Road Traffic Collision
Conclusion: Road Traffic Collision

Cause of death: 1a) Brain haemorrhage 1b) Traumatic head injury (fall)
Conclusion: Misadventure

Cause of death: 1a) Bronchopneumonia and Gastric Perforation 1b) Quetiapine toxicity
Conclusion: Drug related

Cause of death: 1a) Type 2 Respiratory failure 1b) Community acquired pneumonia, Tetraplegia secondary to traumatic Cervical Spine injury
Conclusion: Narrative Conclusion - Death was due to Natural Causes most probably resulting from the injuries he sustained in a Road Traffic Accident in 1988 resulting in a traumatic cervical spine injury rendering Mr Priebe to be tetraplegic and wheelchair dependant.

Cause of death: 1a) Hypoxic brain injury 1b) Cardiac Arrest 1c) Substance misuse 
Conclusion: Drug related

Cause of death: 1a) Cardiac Arrest 1b) Cocaine misuse
Conclusion: Drug related

Cause of death: 1a) Pneumonia 2) Neck of Femur Fracture
Conclusion: Misadventure

Cause of death: 1a) Traumatic brain injury 1b) Alcohol Intoxication
Conclusion: Misadventure

Cause of death: 1a) Pneumonia 2) Severe chronic obstructive pulmonary disease
Conclusion: Misadventure

Cause of death: 1a) Paracetamol Overdose
Conclusion: Suicide

Cause of death: 1a) Congestive Cardiac Failure and Renal Insufficiency 2) Fracture Left Hip (operated)
Conclusion: Narrative Conclusion - David William Francis sadly died on 17/09/2024 at Whiston Hospital Merseyside L35 5DR. David was admitted to hospital on 13/09/2024 having sustained a fracture to his hip following a fall. David had a significant number of serious underlying clinical conditions which adversely affected his ability to recover from such a major insult to his body which necessitated surgery. David's clinical conditions subsequently deteriorated as a consequence of the fall and surgery culminating in his death.

Cause of death: 1a) Acute myocardial insufficiency 1b) Severe coronary artery atheroma 2) Amphetamine use
Conclusion: Narrative Conclusion - Stephen SIMPSON sadly died on 21/07/2024 at 51 Ramford Street St Helens WA9 1QE. Stephen died from natural disease processes that were contributed to by drug use. Stephen had a documented history of amphetamine dependence.

Cause of death: 1a) Fracture of Cervical Spine 1b) Fall 1c) Frailty Of Old Age
Conclusion: Narrative Conclusion - Margaret McCulloch sadly died on 24/09/2024 at 21 Convent of Notre Dame Weld Road Southport Merseyside PR8 2AZ. Margaret suffered with frailty associated with older age and as a consequence she fell at home on 08/09/2024. After initially being admitted to hospital Margaret was discharged home with a palliative care plan aimed at keeping her pain free and comfortable as she approached the end of her life.

Cause of death: 1a) Tapentadol Toxicity
Conclusion: Drug related

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Bronchopneumonia 1b) Cervical spine fracture 2) Ischaemic heart disease and chronic obstructive pulmonary disease
Conclusion: Accident

Cause of death: 1a) Pneumonia 1b) Multiple rib fractures 1c) Fall 2) Chronic Obstructive Pulmonary Disease
Conclusion: Accident

Cause of death: 1a) Combined Drug and Alcohol Toxicity
Conclusion: Suicide

Cause of death: 1a) Multiple Injuries 1b) Fall 2) Ischaemic heart disease
Conclusion: Accident

Cause of death: 1a) Aspiration Pneumonia 1b) Aspiration Pneumonia
Conclusion: Narrative Conclusion - On the evening of 11/11/2023 at about 20.50 hours Peter accidentally fell/collapsed at the side of his bed and even though a crash mat was in situ Peter sustained a catastrophic head injury that caused/contributed to his death. The need for supplementary care had been identified by staff to enable Peter to receive constant supervision but no additional staff were available even though the nurse’s concerns were escalated to managerial staff.

Cause of death: 1a) Sepsis 1b) Bronchopneumonia, Infected Pressure Sores and infective Endocarditis 2) Cortical Atrophy
Conclusion: Natural causes

Cause of death: 1a) Alzheimer's Disease 2) Fractured neck of femur, Type 2 diabetes
Conclusion: Narrative Conclusion - Natural causes, contributed to by the effects of an unwitnessed fall in care home the previous month

Cause of death: 1a) Acute myocardial insufficiency 1b) left ventricular hypertrophy, ischaemic heart disease and abdominal wall haematoma 2) Diabetes mellitus  
Conclusion: Natural causes

Cause of death: 1a) Metastatic carcinoma of the colon
Conclusion: Natural causes

Cause of death: 1a) Cocaine Toxicity
Conclusion: Drug related

Cause of death: 1a) Pneumonia  1b) Traumatic Rib Fracture 1c) Trauma/Fall 2) Alcohol Excess, Intracranial haemorrhage 
Conclusion: Alcohol related

Cause of death: 1a) Haemorrhagic stroke 1b) Infarctive stroke (thrombolysed)
Conclusion: Narrative Conclusion - A recognised complication of necessary treatment

Cause of death: 1a) Malignant mesothelioma of the pleura and metastatic gastro oesophageal cancer 2) Chronic Obstructive Pulmonary Disease
Conclusion: Narrative Conclusion - The industrial disease of mesothelioma in combination with gullet cancer 

Cause of death: 1a) Frailty Of Old Age 2) Displaced proximal humerus fracture
Conclusion: Natural causes

Cause of death: 1a) Combined drug toxicity 2) Haemoptysis secondary to pneumonia
Conclusion: Drug related 

Cause of death: Hanging
Conclusion: Suicide

Cause of death: 1a) Hypoxic Ischaemic Encephalopathy 1b) Pulseless electrical activity cardiac arrest 1c) 2) Mixed anxiety and depressive disorder
Conclusion: Suicide

Cause of death: 1a) Suspension from Ligature
Conclusion: Suicide

Cause of death: 1a) Acute myocardial insufficiency 1b) Obesity cardiomyopathy 2) Cocaine abuse
Conclusion: Narrative Conclusion - Neil John Foster sadly died on 26/07/2024 at 14 Covington Drive St Helens WA9 5RH. Cocaine use is known to have detrimental effects on the heart as does obesity, Neil's Body Mass Index (BMI) was 43.6 at the time of his death which placed Neil in the obese category (greater than 30). Police were satisfied there was no third party involvement in the death of Neil.

Cause of death: 1a) Oesophageal Perforation 1b) Balloon Dilatation of Peptic Oesophageal Stricture
Conclusion: Misadventure

Cause of death: 1a) Strange body in various and other parts of the respiratory tract
Conclusion: Accident

Cause of death: 1a) Chronic Alcohol Dependence 2) Opioid Dependence
Conclusion: Alcohol and Drug related

Cause of death: 1a) Multi organ failure 1b) Decompensated valvular heart disease and portal hypertension 1c) Peritonitis 1d) Perforated, necrotic upper gastrointestinal tract due to radio-frequency ablation of hepatocellular carcinoma 2) Chronic Kidney Disease Stage 4, Atrial Fibrillation
Conclusion: Misadventure

Cause of death: 1a) Mesothelioma
Conclusion: Industrial disease

Cause of death: 1a) Cardiac Arrest 1b) Right Hip Hemiarthroplasty on right fractured neck of femur 1c) Fall
Conclusion: Accident

Cause of death: 1a) Alcohol Toxicity and Cervical Spine Fracture
Conclusion: Alcohol related

Cause of death: 1a) Hypovolemic shock, 1b) Multiple Lacerations to the Neck and Thigh 2) Advanced lung carcinoma
Conclusion: Suicide

Cause of death: 1a) Sertraline Toxicity 2) Myocardial fibrosis
Conclusion: Narrative Conclusion - Valerie Jean Swift was sadly found deceased on 12/07/2024 at 121 Whiteside Road Haydock, St Helens Merseyside WA11 0JB.

Valerie had been prescribed Sertraline for her chronic anxiety and the levels found within her blood were at fatal concentrations. The major risks to life from such toxic levels being arrhythmias, seizures and respiratory depression.

On balance, on the evidence available the cause of Valerie's death was due to Sertraline toxicity but it was also contributed to by naturally occurring myocardial fibrosis. Police were satisfied there was no third party involvement in her death.

Cause of death: 1a) Suspension by ligature 
Conclusion: Suicide

Cause of death: 1a) Traumatic Intracerebral Bleed 2) Dementia, Frailty
Conclusion: Narrative Conclusion - Thomas Alfred Young sadly died on 17/02/2024 at Whiston Hospital Merseyside. Thomas had been admitted to hospital on 30/01/2024 from his care home.

Thomas was admitted to the care home from his home on 31/10/2023, he was admitted after receiving a diagnosis of dementia and due to his cognitive decline, he was opined to no longer be safe living at home in the community. Thomas had also suffered with a number of falls at home. Thomas had a number of underlying clinical co-morbidities in addition to dementia inter alia he had undergone cardiac surgery (valve repair) Atrial Fibrillation and hypertension. At the time of his admission to the care home Thomas was prescribed anticoagulant medication.

On 20/11/2023 in the care home Thomas pulled down the curtains in his bedroom and dining room, he was admitted to hospital because he sustained bruising to his head and a CT scan (dated 21/11/23) demonstrated bilateral subdural haematomas subacute on the left and chronic on the right.

On 29/01/24 Thomas had 3 falls i.e. 02.20, paramedics did not attend, 09.45 paramedics attended, Thomas’ observations were stable and he remained at the care home, and 19.30 paramedics attended and Thomas remained at the care home. Further falls prevention/early identification measures were implemented.

On 30/01/24, the care home contacted the frailty team due to their concerns about Thomas, in particular his increasing agitation and because of the number of falls he had suffered the day before.

On 30/01/2024 at ~09.15 hours Thomas tried to stand up, he lost his balance and fell backwards, he was observed to bang his head and he became increasingly agitated, 999 was called and Paramedics attended, Thomas was subsequently taken to hospital such was the concern by the care home staff and frailty team member about the increased frequency of the falls Thomas was experiencing as well as his deteriorating condition/behaviour.

On arrival at the hospital Thomas was opined to be more confused/agitated than usual. A CT head scan dated 30/01/2024 demonstrated an acute left temporal intraparenchymal haemorrhage. The regional Neurosurgical hospital was contacted but determined Thomas was not suitable/appropriate for neurosurgery. The CT head scan findings were different to those of the scan in November 2023.

The traumatic intracerebral bleed that Thomas had sustained caused his death, but it was also contributed to by naturally occurring underlying clinical conditions in addition to which Thomas was frail, had dementia and he was prescribed anti-coagulant therapy until 23/11/2023. Thomas had also sustained previous head injuries/suffered subdural haematomas probably even prior to admission to the care home. The risks of and from such brain insult were increased due to Thomas’s age, frailty, previous brain/head injury and also anticoagulant medication.

On balance, on the evidence available the bilateral subdural haematomas noted on scan 21 November 2023 were both subacute on the left and chronic on the right. The CT head scan reported on 30/01/2024 showed an acute left temporal intraparenchymal haemorrhage and it was noted the previously demonstrated subdural haematomas (21/11/23) appeared to have resolved.

Notwithstanding all appropriate care and treatment in hospital and previously in the care home, where Thomas had been assessed as being at high risk of falling and where all appropriate aids and preventative measures were in place Thomas’s condition deteriorated culminating in his death.

Cause of death: 1a) Multi-Organ Failure with Hypoxic-Ischaemic Brain Injury 1b) Cardiac Arrest (resuscitated) 1c) Stab Wounds to the Abdomen and Chest
Conclusion: Narrative Conclusion - Ryan Lamb was involved in a violent incident in St Helens on 23/04/2017. Four males were involved in the incident, three of them sustained serious knife inflicted injuries. Ryan was so catastrophically injured that he went into cardiac arrest and notwithstanding all appropriate emergency care and treatment Ryan’s condition deteriorated culminating in his death. The full set of circumstances surrounding the incident which led to the death of Ryan remain unknown and there was insufficient admissible evidence for any individual to be prosecuted for any offence in relation to his tragic death.

Cause of death: 1a) Delirium 1b) Traumatic Rib Fractures 1c) Fall 2) Frailty Of Old Age, Chronic Obstructive Pulmonary Disease, Osteoporosis
Conclusion: Narrative Conclusion - Findings of Fact: Mary Town sadly died on 02/10/2023 at Whiston Hospital Merseyside. Mary had a number of falls in hospital i.e. on 27/08/2023 (2 falls) 17/09/2023 and 29/09/2023.

Mary had been admitted to hospital following a fall at her home on 20/07/2023, she had also suffered from a number of falls at home and she was recognised as being at high risk of falling in hospital, her frail condition had been gradually deteriorating and it was subsequently determined that Mary needed 24 hour residential care. Mary had also been complaining of/believed to have been experiencing pain to the left side of her chest.

Following the fall Mary suffered on 17/09/23 her level of supplementary care was raised from level 3 to level 4 and thereafter it was assessed daily and it remained a either level 3 or level 4 which meant that Mary either had bay supervision or 1-1 care supervision.

On 29/09/23 Mary was found having fallen on the bathroom floor, a CT head scan showed no acute changes and a chest Xray revealed rib fractures on the right side, and due to her underlying frailty and osteoporosis it was likely that she would succumb to fractures relatively easily. Mary’s already poor condition deteriorated following this fall, she became agitated and uncomfortable and on 02/10/2023 palliative care was commenced to keep Mary pain free, peaceful and comfortable as she approached the end of her life.

Because of Mary’s age and multiple co-morbidities including Chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, bronchiectasis and peripheral vascular disease, in addition to which she was found to be Covid positive in August 2023, she was also likely to have had a poor physiological reserve, consequently Mary’s already poor condition deteriorated to the stage at which she was unable to recover.

At the time of Mary’s final fall she should have been supervised at all times, however, due to other patient’s needs Mary was left, albeit for a short period to attend to her own needs on her way into and in the bathroom, this should not have happened, Mary should have been supervised and the fall that Mary sustained caused/contributed to her death, which was also contributed to by other serious naturally occurring, co-existing clinical conditions.

Cause of death: 1a) Frailty Of Old Age 2) Hypertension, Chronic kidney disease (stage 5), Fractured neck of right femur
Conclusion: Narrative Conclusion - Cyril Thompson sadly died on 26/02/2024 at Lakeside View Care Home, 68-69a Promenade Southport Merseyside PR9 0Jb.

Findings of fact: Cyril had been admitted to a different care home from a local hospital on 22/12/2023 where he had been an inpatient on two recent occasions. A “best interests” decision had been made by hospital health care professionals that Cyril now needed full time nursing care. At this care home Cyril had a witnessed fall on 23/12/23 and an unwitnessed fall/collapse on 25/12/23, these two falls did not cause or contribute to the death of Cyril.

Cyril had a care plan and a risk assessment undertaken on his admission to the first care home, he also had a falls mat/alarm in situ in his bedroom and he used a zimmer frame to help his with his walking. Cyril’s risk of falling had been identified and in addition to his frailty Cyril also suffered with periods of agitation.

Cyril who was 95 years of age at the time of his death died from natural causes, however, his death was also contributed to by two significant naturally occurring conditions and also by a fracture to his right hip that he sustained when he had an unwitnessed fall/collapse on 27/12/2023 at about 05.19 hours. Cyril was discovered on the floor in his care home, he appeared agitated and was opined to be shouting at another resident who was also present. Cyril was comforted by care staff to help him to calm down and he also complained of shoulder pain, but not hip/leg pain, at the time he was also able to walk and move to a seat without complaining of hip/leg pain.

At 07.00 hours, Cyril was still complaining of pain in his arm and consequently 999 was called for the attendance of an ambulance.

Cyril was admitted to hospital where it was found he had sustained a fracture to his hip and to his humerus. Cyril underwent surgery to his hip on 28/12/2023, he subsequently made an uneventful recovery from his hip surgery and he was discharged to a different care home where he sadly died, peacefully about 2 months later on 26/02/2024.

Cause of death: 1a) Mixed Drug Toxicity
Conclusion: Drug related

Cause of death: 1a) Asphyxia by suffocation
Conclusion: Suicide

Cause of death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of death: 1a) Intracranial bleed 1b) Head injury 2) Asthma, Chronic Obstructive Pulmonary Disease, Frailty, Acute Coronary Syndrome
Conclusion: Accident

Cause of death: 1a) Covid Pneumonitis 2) Heart failure, Right Fractured Neck of Femur
Conclusion: Natural causes

Cause of death: 1a) Acute Cardiorespiratory failure 1b) Severe pneumonia, Mixed Drug Toxicity
Conclusion: Drug related

Cause of death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of death: 1a) Morphine Toxicity 2) Fatty Liver Disease and Left Ventricular Hypertrophy
Conclusion: Narrative Conclusion - Jason Fagan sadly died on 25/06/2024 at 13 Park Lane West, Bootle L30 3SU.

Jason died from Morphine Toxicity but naturally occurring Liver and heart disease also contributed to his death. Jason had been prescribed Oramorph on 24/06/2024 and a 420 ml bottle was found empty, however, while the blood levels of Morphine were high they were not in the range that is usually considered to be in the fatal range and it is not known exactly how much of the bottle had been actually ingested.

Jason was known to suffer with depression, he also experienced pain in his neck/spinal area which it is understood at times adversely affected his depression. Jason also had a number of other serious clinical conditions including sleep apnoea, extreme obesity, fatty liver disease and left ventricular failure.

Prior to his death, Jason, had been working in his garden at home, it is not possible to know whether this led Jason to suffer from further significant pain and consequently he accidently took too much Oramorph, there was no note of any intention and Jason had enjoyed working in the garden.

On balance not withstanding Jason took the medication that caused his death, which was contributed to by other serious underlying naturally occurring disease, there was insufficient evidence that he took it with the intention of doing so.

Police were satisfied there were no suspicious circumstances surrounding his death.

Cause of death: 1a) Compression of the neck (due to) 1b) Hanging
Conclusion: Suicide

Cause of death: 1a) Type 2 myocardial infarction 1b)
Fractured neck of femur right side (operated) 1c) Mechanical Fall 2) Alzheimer's Disease, Moderate frailty, Left Ventricular Failure
Conclusion: Accident

Cause of death: 1a) Unascertained
Conclusion: Open

Cause of death: 1a) Myocardial Fibrosis 1b) Coronary Artery Atherosclerosis 2) Cirrhosis, and the Effects of Amphetamine and Cocaine
Conclusion: Narrative Conclusion - Natural causes, to which drug use contributed more than minimally.

Cause of death: 1a) Malignant Mesothelioma 2) Frailty Of Old Age
Conclusion: Narrative Conclusion - Malignant Mesothelioma.

Cause of death: 1a) Lower respiratory tract infection 2) Asbestos related Pleural Plaques
Conclusion: Narrative Conclusion -
Natural cause of death, contributed to by a condition developed due to exposure to asbestos at work.

Cause of death: 1a) Ischaemic and Valvular Heart Disease, and Alcohol Toxicity 2) Fatty Liver Disease
Conclusion: Narrative Conclusion - Combined effect of a natural cause and alcohol toxicity.

Cause of death: 1a) Unascertained
Conclusion: Open

Cause of death: 1a) Diabetic Ketoacidosis and Upper Gastrointestinal Tract Haemorrhage 1b) Type 1 Diabetes Mellitus 2) Cocaine use; Fatty Liver Disease
Conclusion: Narrative Conclusion - Natural causes of death, to which the use of cocaine contributed more than minimally.

Cause of death: 1a) Atrial fibrillation and neck of femur fracture (operated) 2) Parkinson's Disease
Conclusion: Narrative Conclusion - Mr Lloyd died on 20th January 2024 at 1155hrs at Whiston Hospital from Natural causes possibly contributed to by the suspension of Apixaban anticoagulation medication used to prevent stroke from Atrial Fibrillation and which medication had been suspended between 10th and 13th January 2024 due to Mr Lloyd experiencing 2 nose bleeds

Cause of death: 1a) The Combined Toxic Effects of Dihydrocodeine and Tramadol
Conclusion: Drug related

Cause of death: 1a) Drowning 2) Chronic obstructive pulmonary disease and Schizophrenia
Conclusion: Narrative Conclusion - On 19th December 2023, following concerns for the welfare of Mr Swift, Police found his body in a body of water situated off Holme Road, St. Helens and known as St. Helens Fishing, Taylor Park, Eccleston Bottom Dam.

The reason for his death was due to drowning and his underlying medical conditions of Chronic Obstructive Pulmonary Disease and Schizophrenia are likely to have indirectly contributed to death by making submersion in water more difficult to survive.

The reason why Mr Swift had entered the water could not be established nor, indeed, could his state of mind and his intention, if any, in so doing.

Cause of death: 1a) Acute myocardial insufficiency 1b) Coronary artery thrombosis 2) Ischaemic heart disease, Idiopathic pulmonary fibrosis
Conclusion: Natural causes 

Cause of death: 1a) Asphyxiation due to choking on food 1b) Oesophageal Cancer
Conclusion: Misadventure 

Cause of death: 1a) Dihydrocodeine Toxicity
Conclusion: Drug related

Cause of death: 1a) Opiate toxicity
Conclusion: Drug related 

Cause of death: 1a) Head injury 1b) Alcohol-Related Liver Disease and Citalopram Toxicity 
Conclusion: Misadventure 

Cause of death: 1a) Mixed Drug Toxicity
Conclusion: Drug related

Cause of death: 1a) Aspiration Pneumonia 1b) Impaired Swallow 1c) C7/8 Spinal Cord Injury
Conclusion: Narrative Conclusion - Valerie Westall sadly died on 30/07/2024 at Southport Hospital PR8 6PN. Valerie was admitted to hospital on 25/07/2024, as well as having a number of medical problems Valerie had suffered a spinal cord injury in 2017 when she fell down some steps as a consequence of a syncopal (fainting) episode. The spinal cord injury to Cervical spines 7/8 left Valerie tetraplegic. Valerie was an inpatient at Southport spinal injuries unit until 03/06/2019.

The injuries to cervical spines 7/8 of the spinal cord and tetraplegia left Valerie at risk of chest, infection and swallow related problems and notwithstanding all appropriate care and treatment in hospital Valerie's condition deteriorated culminating in her death. 

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Frailty of Old Age 2) Fracture neck of femur left hip, Congestive heart failure, Liver Cirrhosis, Pneumonia.
Conclusion: Narrative Conclusion - Doreen Hachula sadly died on 24/11/2023 at Whiston Hospital Merseyside.

Doreen was admitted to hospital on 24/09/2023 with reduced levels of consciousness, and shortness of breath, she had a significant past medical history and she was becoming increasingly frail, Doreen’s frailty score was 8 i.e. Doreen was severely frail (completely dependent approaching the end of her life).

Doreen was treated for a chest infection (pneumonia) and decompensated heart failure.

On 29/09/2023 Doreen was found on the floor on the ward, she had pain in her hips and knees the fall or collapse was unwitnessed, but Doreen sustained a fracture to her left hip.

Doreen was not fit enough to undergo surgery for the fracture to her hip and she was therefore treated conservatively.

Doreen subsequently passed away peacefully. The fracture to her hip sustained when Doreen collapsed or fell contributed to the death of Doreen along with her other serious clinical co-morbidities, her death was however, caused by her severe frailty due to her advanced age.

Cause of death: 1a) Adenocarcinoma of the Rectum with Liver Metastases 2) Subdural haematoma

Conclusion: Narrative Conclusion - Henry Francis Thomas Roth (Known and referred to as Frank) sadly died on 20/07/2023 at 5 Hollingsworth Court, Cansfield Street, St Helens WA10 1LU. Frank suffered with terminal rectal cancer that had spread to his liver. Frank was unsuitable for a major bowel resection, he had declined a stoma, which may have helped with symptom management, and he had subsequently declined chemotherapy, he had the capacity to do so.

On 09/06/2023 Frank was admitted to hospital with rectal bleeding and diarrhoea. The management of Frank was aimed at providing supportive care to manage his symptoms as far as this was possible.

On 13/06/2023 Frank was standing up from his chair when he fell/collapsed on the ward. A subsequent CT scan confirmed Frank had at some point in time sustained a subdural haematoma. No neurosurgical intervention was appropriate.

On 16/06/2023 Frank underwent a second CT scan because of increasing confusion, however, there was no worsening of the subdural haematoma.

Frank, at his/his wife’s request was appropriately discharged home on 30/06/2023, with support and with a DNAR Order in place to enable Frank to die peacefully, pain free and with dignity at home when the time came.

The subdural haematoma (on balance more than negligibly, minimally or trivially) contributed to Frank’s death which was, however, caused by terminal rectal cancer which had metastasised to his liver.

Cause of death: 1a) Subdural Haematoma, Intracerebral bleed
Conclusion: Accident

Cause of death: 1a) Acute Methadone Toxicity
Conclusion: Drug related

Cause of death: 1a) Multi organ failure 1b) Neuroleptic Malignant Syndrome 2) Schizophrenia
Conclusion: Misadventure

Cause of death: 1a) The Toxic Effects of Methamphetamine 2) Aortic Valvular Disease, Ischaemic Heart Disease
Conclusion: Drug related

Cause of death: 1a) Acute alcohol toxicity
Conclusion: Alcohol related

Cause of death: 1a) Bronchopneumonia and mixed drug toxicity
Conclusion: Drug related

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Ischaemic bowel 1b) Type 2 Diabetes, peripheral vascular disease and osteomyelitis and 5th ray amputation (operated 11/7/24)
Conclusion: Natural causes  

Cause of death: 1a) Myocardial infarct 2) Left side Neck of Femur Fracture (Operated) 
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall at home.

Cause of death: 1a) Multiorgan Failure 1b) Rib Fractures due to fall 1c) Alcohol Excess
Conclusion: Alcohol related  

Cause of death: 1a) Cocaine Toxicity and Coronary Artery Atherosclerosis 2) Fatty Liver Disease 
Conclusion: Drug related

Cause of death: 1a) Infected Left Hip Wound 1b) Left neck of femur fracture (operated) 2) Dementia, frailty
Conclusion: Accident

Cause of death: 1a) Traumatic intracranial haemorrhage 2) Dementia, Atrial Fibrillation
Conclusion: Accident 

Cause of death: 1a) Asphyxia
Conclusion – Narrative Conclusion - Died from his own actions, whilst of disturbed mind.

Cause of death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of death: 1a) Bowel ischaemia 1b) Thermal burns injury
Conclusion: Accident  

Cause of Death: 1a) Malignant mesothelioma of the left pleura 1b) Asbestos
Conclusion: Industrial disease

Cause of Death: 1a) Renal Failure 1b) Rhabdomyolysis 1c) Fall and Long Lie 2) Frailty, Dementia
Conclusion: Narrative Conclusion - Mr Foster died from the effects of having suffered an unwitnessed fall at his home.

Cause of Death: 1a) Spinal fractures 1b) Fall
Conclusion: Accident

Cause of Death: 1a) Congestive cardiac failure and aspiration pneumonia 2) Previous anoxic brain injury
Conclusion: Narrative Conclusion - Natural causes contributed to by health complications arising from a brain injury suffered in childhood.

Cause of Death: 1a) Myocardial infarction 2) Self-neglect, Malnutrition, Left distal femur fracture
Conclusion: Narrative Conclusion - Natural causes contributed to by neglect

Cause of Death: 1a) Hanging
Conclusion: Narrative Conclusion - Skertion Allkushi was found to have taken his own life by using a ligature with which to hang himself from Linacre Bridge, Linacre Lane L20 on 14th April 2024. His state of mind at the time of taking his own life has not been ascertained.

Cause of Death: 1a) Asphyxiation due to choking on food 2) Frailty, Meningioma, Previous stroke
Conclusion: Accident

Cause of Death: 1a) Consistent with drowning
Conclusion: Open

Cause of Death: 1a) Pneumonia 1b) Cardiac arrest following choking episode
Conclusion: Accident

Cause of death: 1a) Severe Burns
Conclusion: Accident

Cause of death: 1a) Aspiration pneumonitis 2) Down's Syndrome, Dementia, Frailty
Conclusion: Natural causes

Cause of Death: 1a) Severe Hypoxic Brain Injury 1b) Cardiac Arrest 1c) Left medulla oblongata and cerebellar stroke
Conclusion: Natural causes

Cause of death: 1a) Aneurysmal Subarachnoid Haemorrhage
Conclusion: Narrative Conclusion - John Raymond Pulford died from a catastrophic aneurysmal subarachnoid haemorrhage. All emergency care was initiated in a timeously manner following his presentation to hospital on 03/11/2023. John was stabilised and transferred to the regional speciality centre later the same evening, but sadly John was unable to survive this catastrophic event and death was confirmed on 05/11/2023.

John underwent MRI head/brain scans in August 2021, a basilar tip aneurysm was present on the MRI scan, but the radiologist did not see it and consequently he did not report the finding which went undiagnosed and untreated, this was due to human error.

Because the diagnosis was missed on MRI in 2021 John did not undergo surgical prophylactic intervention in the form of endovascular coiling, the risk profile is 1% i.e. below the 5% that was John’s risk of spontaneous haemorrhage, apart from the problems associated with the missed aneurysm John was otherwise fit and well.

On the balance of probability if the diagnosis had not been missed,

1. John would have been offered endovascular coiling, the treatment risks are low, and the success rate is high.

2. It is likely John would not have bled with the treatment i.e. it is most likely the risk of bleeding would have been averted.

3. The risk of bleeding in John without prophylactic treatment with endovascular coiling being 5% while the risks associated with the treatment (Endovascular coiling) being low at 1%, however because the diagnosis was missed due to human error in August 2021, the treatment, which would have been likely to avert the risk of bleeding was not considered and the treatment was not offered or performed, there was no clinical management plan or follow up in respect of the aneurysm and the risk of aneurysmal bleeding materialised causing John’s death.  

Cause of Death: 1a) Acute myocardial insufficiency 1b) Cardiomegaly, Myocardial Fibrosis 1c) Combined Cocaine and Methadone Toxicity
Conclusion: Narrative Conclusion - Jodie Sheree GREEN was found deceased on 31/03/2024 at Chapel Street Southport. Jodie was found in the street where she had been sleeping rough. CPR was commenced and Jodie was taken to Southport Hospital where CPR was continued but was unsuccessful. Police were satisfied there was no third party involvement in her death which was caused by catastrophic cardiac problems, which arose/were contributed to as a consequence of cocaine and methadone toxicity. Jodie had a long term history of methadone dependence.

Cause of Death: 1a) Pulmonary Embolism and Pneumothorax 1b) Long lie, deep vein thrombosis and rib fractures 1c) Left Total Anterior Circulation Infarct and collapse 2) Atrial Fibrillation, Type 2 Diabetes
Conclusion:  Narrative Conclusion - Alan Robert HOUNSELL sadly died on 25/06/2024 at Whiston Hospital L35 5DR. Alan was admitted to hospital on 23/06/2024 after probably collapsing from a stroke at home some time within the circa previous 5 days. Alan fractured his ribs when he collapsed which led to a pneumothorax and the time spent immobile on the floor probably caused the pulmonary embolism both of which caused the death of Alan. Alan was unable to survive the naturally occurring medical event and the consequences that followed, passing away peacefully as stated.

Cause of Death: 1a) Bilateral Subdural Haematoma with acute haemorrhage 2) Frailty of old age, Pneumonia
Conclusion: Narrative Conclusion - Derek Arthur MOORES sadly died on 25/06/2024 at Whiston Hospital Merseyside L35 5DR. Derek was admitted to hospital on 22/06/2024 following a fall when he hit his head on the bedside table. Derek also had a significant number of serious underlying clinical co-morbidities, the injuries that he suffered were catastrophic and led to his death. Derek's death was also contributed to by his frailty and pneumonia.

Cause of Death: 1a) Hepatic encephalopathy 1b) Hepatorenal Syndrome 1c) Decompensated Chronic liver disease 2) Infection (Skin/Abdominal Wall), Psoriatic arthropathy on Methotrexate, Type 2 Diabetes Mellitus, Hypertension
Conclusion: Narrative Conclusion - Leslie John Wilson died after being admitted to hospital on 28/12/2023. Leslie was seriously unwell, his liver disease decompensated, and this caused his death. The liver disease from which Leslie suffered was caused/contributed to by infection, diabetes mellitus, alcohol consumption, raised blood pressure, obesity (BMI of 34) and Methotrexate which can be hepatotoxic. Methotrexate had been properly administered and monitored since it had been prescribed in 2017 in accordance with evidence-based practice and it was not administered from 19th December onwards. It is not possible to state to what degree each factor contributed to the death of Leslie.

Cause of Death: 1a) Oxycodone toxicity
Conclusion: Narrative Conclusion - Veronica Stanley sadly died on 23/04/2024 at 116 Whiteside Road Haydock Merseyside WA11 0JB. Veronica had a past medical history of alcohol dependency, osteopetrosis and recurrent hip fractures and she was also partially sighted. The significant documented clinical history also includes, anxiety/depression, chronic pain, hypothyroidism, seizures following a head injury (1998) and discectomy and fusion of C4/5 5/6 in 2016. Veronica collapsed on 17/04/2024 and was witnessed to have a type of seizure. On 22/04/2024 Veronica was believed to have collapsed again at home and was assisted back to bed. A bottle of prescribed Oramorph was taken out of the room. At about 00.30 hours (23/04/2023) Veronica was asleep and snoring but when she was next looked in on at about 10 00 hours, she was unresponsive in the same position in bed. CPR was commenced but it was unsuccessful. The Oramorph was prescribed for pain management. Toxicological analysis did not find Oramorph (Liquid Morphine) but Oxycodone which was found on toxicological analysis is an opioid drug prescribed for pain relief. At toxic levels Oxycodone can cause respiratory depression and death. Death was most likely (on balance) as a consequence of the toxic effects of oxycodone. Veronica took the Oxycodone which led to her death, but there was insufficient evidence that she took it with the intention of taking her own life, that was not found on the evidence available.

Cause of Death: 1a) Bronchopneumonia 2) Effects of codeine, Ischaemic heart disease
Conclusion: Narrative Conclusion - Catherine Parry sadly died on 09/04/2024 at Aintree University Hospital Liverpool. Catherine was admitted to hospital on the date of her death, she had felt unwell for about 4 days. Catherine had a significant number of underlying clinical co-morbidities including, hypertension, epilepsy, previous subarachnoid haemorrhage with aneurysms clipping and diverticular disease with de-functioning ileostomy. Catherine also suffered with chronic pain and she was immobile and had been bedbound for about 5 years. Catherine was also alcohol dependant.18 codeine tablets were missing from the medication package. Catherine was extremely unwell on admission and notwithstanding treatment was administered, her condition continued to deteriorate culminating in her death. Catherine died from pneumonia, but codeine can also cause cardio respiratory depression, when taken in excess, she also had underlying heart disease which also contributed to her death. Catherine took the excessive quantity of codeine that contributed to her death, but on balance, there was insufficient evidence that she took Codeine with the intention of taking her own life.

Cause of Death: 1a) Femoral Artery Occlusion 2) Frailty, Fall, Alcohol abuse (Historical)
Conclusion: Narrative Conclusion - Raymond Jeffrey DARGUE sadly died on 16/06/2024 at Birkdale Park Nursing Home 6 Lulworth Road Southport PR8 2AT. Raymond was in receipt of palliative care from about 02/05/2024, he subsequently developed femoral artery occlusion which caused his death, but it was contributed to by his frailty, a previous fall with long lie and (historical) excess alcohol consumption in the past, Raymond stopped drinking completely in 2021. Raymond had a significant number of underlying clinical co-morbidities including, Left ventricular failure, Mitral stenosis, Aortic stenosis, and femoral artery occlusion. Raymond suffered a fall at home with a long lie on the floor of about 2 days, he was admitted to hospital on 17/04/2024, he was subsequently admitted to a nursing home on 08/05/2024, with opioid medication to help to keep him pain-free and comfortable as he approached the end of his life.

Cause of Death: 1a) Pneumonia 2) Distal femoral fracture and wound infection, Peripheral vascular disease, Atrial fibrillation
Conclusion: Narrative Conclusion - Shirley Anne Stevens sadly died on 19/06/2024 at Whiston Hospital Merseyside L35 5DR. Shirley was admitted to hospital on 10/06/2024 with shortness of breath, she was treated for pneumonia and a wound infection at the site of her orthopaedic surgery for a fracture to her femur 5 weeks previously. Shirley who had a number of underlying co-morbidities including, gout, chronic kidney disease (stage 3), atrial fibrillation, inflammatory bowel disease and peripheral vascular disease, was unable to respond to treatment, and her condition deteriorated, culminating in her death.

Cause of Death: 1a) Pneumonia 2) Neck of Femur Fracture, Fall/Trauma, Chronic obstructive lung disease
Conclusion: Narrative Conclusion - Edmund Patrick John MOONAN sadly died on 16/06/2024 at Whiston Hospital Merseyside L35 5DR. Edmund was admitted to hospital on 11/06/2024 following an unwitnessed fall at home, Edmund suffered a fracture to his hip when he fell. Edmund was commenced on antibiotics, for a possible chest infection and following anaesthetic review he was found to be unfit at that time for theatre. Edmund had a significant medical history including suffering with dementia, Chronic Obstructive Pulmonary Disease, previous episodes of pneumonia and hypertension (High blood pressure). Edmund was unable to recover, and his condition deteriorated culminating in his death.

Cause of Death: 1a) Intracranial bleed 1b) Skull Fracture 2) Diabetes, Hypertension
Conclusion: Narrative Conclusion - Patricia Carney sadly died on 18/06/2024 at Whiston Hospital Merseyside. Patricia was admitted to hospital on 16/06/2024. Patricia had sustained a serious head injury/insult with intracranial bleeding and mass effect. Patricia reported suffering a brief loss of consciousness, she lost the power in her legs followed by collapsing backward to the ground. The insult Patricia suffered to her head proved catastrophic. Neurosurgical intervention was not an option and her condition continued to deteriorate culminating in her death.

Cause of Death: 1a) Asphyxia 1b) Food Inhalation 2) Malignant Mesothelioma, Parkinsons Disease
Conclusion: Narrative Conclusion - Edward Alan Hannaby, known as and referred to as Ted sadly died on 29/10/2023 at Aaron Grange Care Home Liverpool L36 5XG.

Ted had a significant past medical history which included, Parkinson’s disease, vascular dementia and Malignant Mesothelioma.

Ted had a DNAR Order in place and he had been a care home resident for about 18 months at the time of his death.

Ted, had no previous history of choking at the care home, he was assessed as being at low risk of choking, however, the presence of malignant mesothelioma would have significantly compromised Ted’s breathing and functional reserve. The malignant mesothelioma, which is usually caused by asbestos exposure, contributed to but did not cause Ted’s death.

Parkinson’s disease is a serious movement disorder, which may have increased the risk of choking from food inhalation.

In December 2021 on assessment prior to Ted becoming a permanent resident Ted’s wife had noticed Ted was starting to struggle to swallow food, however in the care home Ted was assessed and required a normal diet and fluids, his meals were supervised, staff would cut up meat for him and there had been no previous choking or similar episodes.

On 29/10/2023 at about 11am Ted was eating a single piece of orange segment (possibly Jaffa/large orange) in the communal area, a member of staff was present handing out orange segments, she turned around to hand out the segments to other residents and when she turned back Ted appeared to be chocking, the member of staff commenced back slaps, summoned help immediately and initiated a 999 call.

More senior staff took over and abdominal thrusts were also performed.

CPR was commenced and the orange was dislodged. Paramedics arrived a short while later and CPR was subsequently discontinued. There was a DNAR Order in place.

The tragic, accidental choking episode caused Ted’s death which was also contributed to by mesothelioma, which is usually associated with asbestos exposure and Parkinson’s disease with dementia, which arises naturally.

Cause of death: 1a) Pneumonia 2) Fall with multiple fractures
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an accidental fall.

Cause of death: 1a) Paracetamol toxicity
Conclusion: Narrative Conclusion - Died as a result of taking an overdose of prescription medication with unknown intent.

Cause of death: 1a) Combined Heroin, Methadone, Cocaine Toxicity
Conclusion: Drug related

Cause of death: 1a) Pneumonia 1b) Chronic Obstructive Pulmonary Disease 2) Hip fracture (Operated)
Conclusion: Natural causes   

Cause of death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of death: 1a) Unascertained
Conclusion: Narrative Conclusion - Dianne Kinsella 78 years of age sadly died on 31/12/2021 at Southport Hospital Merseyside. Dianne was seriously unwell when she was admitted to hospital on 07/12/2021, she was extremely frail, had contracted Covid pneumonitis, she had had a cerebral vascular accident in August 2021, historical, treated cancer of her bladder and type II Diabetes mellitus which was being controlled with insulin. Dianne had tested positive for Covid 19 and she was initially admitted and managed in the dedicated Covid ward. Prior to admission Dianne had been struggling to breathe, her breathing had become shallow and laboured she had been coughing and unable to take her medication. The diagnosis was that of Covid positive with aspiration pneumonia. On 28-29/12/2021 after a period of relative stability, Dianne’s condition started deteriorating, and the consultant opined, due to her extreme frailty, serious underlying clinical co-morbidities and poor physiological reserve there was no further treatment that would be likely to improve her grave state, consequently active treatment was subsequently ceased, and the emphasis shifted to that of providing comfort and peace as Dianne approached the end of her life. Dianne was commenced on end-of-life palliative care, to enable her to die a peaceful, pain-free and dignified death. On 29/12/2021-30/12/2021 it was noted that Dianne was unconscious and peaceful. On 31/12/2021 at about 03.30 another patient with serious mental health related problems, without any justifiable cause placed 2 pillows over Dianne’s face, holding them down for about 5-10 seconds when nurses who responded immediately were able to remove the patient who was depressing the pillows over the face of Dianne, remove the pillows and call the police and security. The doctor was already on the ward. The doctor attended to Dianne immediately, the doctor noted Dianne, who remained unconscious was still breathing, there were no changes to her previous breathing pattern, the doctor listened to her chest, she was not distressed or restless, she did not appear to be injured at all, she remained in receipt of palliative care as she approached the end of her life and her oxygen saturation remained at 98%. Dianne passed away c5.5 hours later, and the timing of her death was expected, death had been imminent. A Home Office pathologist who undertook a comprehensive post mortem examination was unable to ascertain the cause of death to the requisite standard, nor were they able to find the tragic events accelerated Dianne’s death, there was no pathological evidence to support this, in particular there were no findings of petechial haemorrhages around the eyes or mouth or inside the mouth, there were no injuries to the face, neck, head or skull, and there were no hyoid bone or laryngeal changes or any injuries at all. The pathologist was also cognisant of Dianne’s naturally occurring serious underlying clinical co-morbidities, the fact that Dianne was unconscious, she was extremely frail, she was bedbound and at the time of her death she was in receipt of palliative care as approached the end of her life. The patient who placed two pillows over Dianne’s face had been admitted to hospital following a serious overdose of medication and she was initially treated in intensive care, she was subsequently managed on the ward, a Mental Health Act assessment on 29/12/2021 found she had capacity, but she remained a risk to herself (but not others) and consequently she was waiting for a mental health bed. The delay in assessing this patient’s mental health needs did not affect the outcome because at the time of this tragic incident she was again assessed as having capacity. Following these events, this patient was arrested and taken into custody as opposed to a mental health facility, however, her mental state deteriorated, and she was subsequently sectioned under the Mental Health Act. Two psychiatrists found this patient lacked capacity and her condition continued to deteriorate, they concluded she was unfit to stand trial and in July 2023 a judge ordered the matter should lie on the file because she was unable to stand trial and most likely never would. Consequently, even though this patient put pillows over the face of Dianne, without any justifiable cause, when Dianne was already unconscious and naturally approaching the end of her life no prosecution for any offence was able to follow, and this patient is also now deceased. In sum, when Dianne passed away c5.5 hours later, the timing of her death was expected and had been imminent.

Cause of Death: 1a) Unascertained
Conclusion: Drug related

Cause of Death: 1a) Pulmonary embolism 1b) Fractured Right Neck of Femur(operated) 2) Left Ventricular Systolic Dysfunction
Conclusion: Accident

Cause of Death: 1a) Intracranial haemorrhage 1b) Fall
Conclusion: Accident

Cause of Death: 1a) Hospital Acquired Pneumonia 1b) Stroke 2) Hip fracture, Asthma
Conclusion: Natural causes 

Cause of Death: 1a) Epithelioid Mesothelioma
Conclusion: Industrial disease

Cause of Death: 1a) Fracture neck of femur 1b) Trauma/Fall
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of a fall in care home

Cause of Death: 1a) Dihydrocodeine Toxicity and Pneumonia
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of taking excessive prescription medication, with unknown intent.

Cause of Death: 1a) Hospital-acquired pneumonia 1b) Laparotomy and reversal of ileostomy (operated)
Conclusion: Narrative Conclusion - Recognised complications arising from necessary surgery

Cause of Death: 1a) Unascertained
Conclusion: Natural causes

Cause of Death: 1a) Streptococcal Bacteraemia 1b) Cellulitis 2) Fracture neck of femur, Congestive Heart Failure, Covid 19, Chronic kidney disease, Ischaemic heart disease, type 2 diabetes.
Conclusion: Narrative Conclusion - John Gavin sadly died on 30/08/2023 at Whiston Hospital Merseyside. John was admitted to hospital on 12/08/2023 with fever, cough and difficulty breathing, he was extremely unwell.

John had a significant number of serious underlying clinical co-morbidities including type 2 diabetes mellitus, leg ulcers, chronic kidney disease stage 3, ischaemic heart disease, congestive cardiac failure, atrial fibrillation and hypertension.

John was immediately commenced on antibiotics for serious infection, he was also being investigated for possible left leg osteomyelitis. During the course of his treatment John collapsed/fell, his blood sugar was very low at the time at 2mmol/l and he sustained a fracture to his neck of femur, John also developed an acute kidney injury in addition to his chronic kidney disease and he contracted Covid 19. John was clinically too unwell to undergo orthopaedic surgery.

Throughout his admission John’s diabetes was unstable, as often can be the case, due to severe infection and ill health and consequently it was being monitored regularly.

Notwithstanding his clinical management with antibiotics, his diabetic management and treatment given for an acute kidney injury his renal function declined and he also developed pulmonary oedema.

The spiralling deterioration continued, and subsequently active treatment was changed to palliative care to enable John to have a pain free, dignified and peaceful death.

The fracture to John’s leg contributed to his death along with a number of other natural clinical co-morbidities but his death was caused by a serious, naturally occurring, and ultimately catastrophic infection (bacteraemia).

Cause of Death: 1a) Hypoxic brain injury 1b) Depression, Mixed Overdose
Conclusion: Narrative Conclusion - Rosaleen Mary Buckley sadly died on 05/11/2023 at Whiston Hospital Merseyside. Rosaleen was admitted to hospital on 26/08/2023, she was discovered unconscious following a mixed drug overdose. Rosaleen was critically ill and required ventilatory support in intensive care.

Rosaleen subsequently recovered sufficiently to return home, and she was discharged from hospital on 04/09/2023. Rosaleen had returned to her baseline health, she had been going out and had even been well enough to play golf after her discharge.

On 14/09/2023 Rosaleen was readmitted to hospital she was again seriously unwell, she was confused and became increasingly confused, until, notwithstanding all appropriate medical care and treatment she became unconscious.

Rosaleen necessarily had a CT head scan under general anaesthetic 10/10/2023 which showed anoxic brain damage consistent with delayed post hypoxic leukoencephalopathy (DPHL).

Rosaleen no longer had capacity to make her own decisions and on 01/11/2023 at a best interest decision meeting, the decision was taken to treat her symptoms palliatively to enable Rosaleen to die in peace, pain free and with dignity and she passed away peacefully as stated.

On the second admission to hospital, notwithstanding the mixed medication overdose (first admission) contributed to Rosaleen’s death, the delayed brain injury was a relatively rare and unforeseen event.
 

Cause of death: 1a) Dihydrocodeine Toxicity 2) Anxiety and Depressive Disorder Chronic Obstructive Pulmonary Disease
Conclusion: Suicide  

Cause of death: 1a) Multiple Injuries
Conclusion: Road Traffic Collision

Cause of death: 1a) Aspiration Pneumonia 1b) Traumatic Rib Fracture 2) Frailty, Congestive cardiac failure
Conclusion: Natural causes

Cause of death: 1a) Cocaine Toxicity
Conclusion: Drug related

Cause of death: 1a) Traumatic Subdural Haematoma 1b) Fall 1c) Dementia
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall in care home.

Cause of death: 1a) Haemorrhagic Shock 1b) Fracture Femur
Conclusion: Accident

Cause of death: 1a) Lung Mesothelioma 1b) Asbestosis Lung
Conclusion: Industrial disease 

Cause of death: 1a) Subdural haematoma 1b) Fall 2) Hospital Acquired Pneumonia
Conclusion: Accident

Cause of Death: 1a) Cardiorespiratory Failure 1b) Pneumonia and Congestive Cardiac Failure 2) Asbestosis
Conclusion: Narrative Conclusion - Leslie Enas MADELOSO sadly died on 01/04/2024 at 39 Sidney Powell Avenue Liverpool L32 0TL. Leslie died from natural causes, he had a significant history of diagnosed heart disease, however, his death was contributed to by Asbestosis. A biopsy taken at post mortem showed a fibre count in the right lung was elevated to more than the reference range for normal ambient exposure to asbestos, consequently the pathologist opined asbestosis contributed to the death of Leslie, the main causes being natural. No malignancy was seen on post mortem examination.

Cause of Death: 1a) Traumatic intracranial haemorrhage 1b) Skull Fracture 1c) Osteoporosis, frailty fall/collapse 2) Recurrence of Breast Cancer, Chronic Kidney Disease, Frailty of Old Age
Conclusion: Narrative Conclusion - Dorothy Sutton sadly died on 25/05/2024 at Whiston Hospital Merseyside. Dorothy was 94 years of age at the time of her death. Dorothy had a number of serious underlying co-morbidities and she was also very frail. Dorothy was admitted to hospital on 17/05/2024 following an unwitnessed fall/collapse. Dorothy sustained catastrophic injuries and she passed away peacefully as stated.

Cause of Death: 1a) Infective exacerbation of chronic obstructive pulmonary disease 2) Fracture of the Sternum, Heart Failure
Conclusion: Narrative Conclusion - Margaret Mary Perry sadly died on 24/05/2024 at Southport Hospital Merseyside PR8 6PN. Margaret was admitted to hospital on 04/05/2024 following a collision with a stationary car, which she struck when the car she was driving crossed to the wrong side of the carriageway. Margaret sustained a fracture to her sternum which contributed to but did not cause her death, which was from an exacerbation of chronic obstructive pulmonary disease which did not respond to treatment and Margaret passed away peacefully as stated.

Cause of Death: 1a) Multi Organ Failure (due to) 1b) Malnutrition 1c) Duodenal Switch 2) Crohns disease
Conclusion: Narrative Conclusion - On 12th May 2023, Mrs Gregory was admitted into Whiston Hospital for: rehydration; nutritional concerns and replacement of electrolytes. Post admission, the condition of Mrs Gregory continued to deteriorate and she developed multi-organ failure secondary to Malnutrition. Mrs Gregory was placed on palliative care and continued to receive such until life was pronounced extinct at 15.43hrs on 24th June 2023. Mrs Gregory had previously undergone a Duodenal Switch Operation at Leeds Nuffield Hospital on 25th October 2022 and further surgery resulting therefrom at Whiston Hospital on 31st October 2022

Cause of Death: 1a) Multiorgan Failure 1b) Urosepsis 1c) Urinary tract infection 2) Frailty, Quadriplegia
Conclusion: Narrative Conclusion - Colin John Bailey sadly died on 24/05/2024 at Whiston Hospital Merseyside L35 5DR. Colin was admitted to hospital on 22/05/2024, he was seriously unwell with a urinary tract infection, which led to sepsis and ultimately to his death from multi organ failure. John was frail and quadriplegic following an accident many years previously, both of these clinical manifestations contributed to his death.

Cause of Death: 1a) Malignant Mesothelioma 2) Heart failure
Conclusion: Narrative Conclusion - Frank Donald Thornley sadly died on 18/05/2024 at Parr Care Home 42 Fleet Lane St Helens WA9 1SX. In January 2024 Frank had a pleural biopsy and talc pleurodesis. Numerous nodules were found throughout the thickened parietal pleura and biopsy showed a mixed epithelioid/sarcomatous mesothelioma. Frank's death was caused by malignant mesothelioma which is usually associated with asbestos exposure, but it was also contributed to by naturally occurring heart failure. In life Frank had been employed inter alia in plumbing and mechanical services in addition to a health authority since 1975- 1989.

Cause of Death: 1a) Frailty Of Old Age 2) Fractured neck of femur, Dementia
Conclusion: Narrative Conclusion - Ernest Francis Beeston sadly died on 19/05/2024 at Whiston Hospital Merseyside. Ernest who was 92 years of age was admitted to hospital in December 2023 following a fall in his bedroom, he underwent surgery for a fracture to his left hip on 18/12/2023, he was subsequently transferred for intermediate care on 07/02/2024 only to be readmitted to the acute ward the following day for treatment for pneumonia, constipation, pain management and delirium. Ernest's condition improved slightly, only to deteriorate again, and he became increasingly frail as he approached the end of his life, passing away peacefully as stated. The fracture contributed to the death of Ernest along with dementia.

Cause of Death: 1a) Subdural Haemorrhage 1b) Witnessed collapse
Conclusion: Narrative Conclusion - June was admitted to hospital on 07/10/2023 following a fall at home, she had also been experiencing dizzy spells. A CT head/brain scan on admission was normal, showing no evidence of bleeding or trauma. June’s Troponin levels were raised, and an echocardiogram showed impaired left ventricular function. June was therefore commenced on the Acute Coronary Syndrome (ACS) pathway; treatment was commenced, and she was transferred to the cardiology ward. On 13/10/2023 June complained of some chest pain at about 05.00 hours, and she was reviewed by a doctor at about 07.00hours, later on the same morning June reported having headache/s to the nursing staff. At about 12 noon, when the consultant cardiologist was on the ward, June collapsed while walking with her Zimmer frame, she complained of feeling dizzy prior to collapsing. June was witnessed by the cardiologist to hit the right side of her head against the arm of a wheelchair and then the back of her head against the wall. June’s condition subsequently rapidly deteriorated, resuscitation was commenced immediately and an urgent CT scan showed a large subdural haemorrhage The subdural haemorrhage proved to be catastrophic, and June died on ITU a short while later.

Cause of Death: 1a) Extensive subdural haematoma 1b) Fall with head injury 2) Anticoagulation Therapy, Atrial Fibrillation
Conclusion: Narrative Conclusion - Roy Dingsdale was admitted to hospital on 29/03/2023 with cellulitis and decompensated heart failure, for which he was responding well to treatment. On 04/04/2023, Roy fell/collapsed on the ward, he was on anticoagulant therapy, and he sustained a catastrophic injury to his head/brain. Roy was unsuitable for neurosurgery, and his condition continued to deteriorate necessitating the commencement of palliative care. Roy subsequently passed away peacefully as stated.

Cause of death: 1a) Acute on Chronic Ischaemic Subdural Haematomas 2) Alzheimers disease, Hypertension
Conclusion: Natural causes 

Cause of death: 1a) Pulmonary emboli 1b) Congestive cardiac failure 2)
Ischaemic heart disease
Conclusion: Natural causes  

Cause of Death: 1a) Mediastinal haemangioendothelioma (operated) and mixed drug toxicity 2) Type 2 diabetes mellitus
Conclusion: Narrative Conclusion - Natural causes contributed to by ingestion of an excessive quantity and combination of drugs

Cause of Death: 1a) MDMA Toxicity 
Conclusion: Drug related

Cause of Death: 1a) Hypoxic brain injury 1b) Cardiac Arrest 1c) Asphyxiation by hanging
Conclusion: Suicide

Cause of Death: 1a) Ischaemic heart disease and mixed drug use 2) Chronic Obstructive Pulmonary Disease
Conclusion: Drug related

Cause of Death: 1a) Lower respiratory tract infection 2) Right Neck Of Femur Fracture (Operated), Frailty
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of a previous fall at home.

Cause of Death: 1a) Frailty Of Old Age 2) Hypertension, Stroke, Chronic kidney disease, Subdural Haemorrhage
Conclusion: Natural causes

Cause of Death: 1a) Multi-organ failure 1b) Infective endocarditis 1c) Intravenous drug use
Conclusion: Drug related

Cause of Death: 1a) Aspiration Pneumonia 1b) Spinal Cord Injury
Conclusion: Natural causes

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Multiple Injuries
Conclusion: Suicide

Cause of Death: 1a) Myocardial infarction 1b) Heart failure 2) Fractured neck of femur
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an earlier fall at home.

Cause of Death: 1a) Stab wound to the heart (self inflicted)
Conclusion: Narrative Conclusion - Died from a self-inflicted stab wound whilst in a disturbed state of mind.

Cause of Death: 1a) Subarachnoid Haemorrhage 2) Atrial Fibrillation, Hypertension
Conclusion: Accident

Cause of Death: 1a) Bronchopneumonia 1b) Pulmonary emphysema and fractured ribs 2) Coronary artery atheroma
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall at home.

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Empyema and Gall Bladder Fossa Abscess 1b) Laparoscopic Cholecystectomy 1c) Previous Bilary Sepsis with Liver Abscess 2) Ischaemic Heart Disease, Morbid Obesity
Conclusion: Misadventure

Cause of Death: 1a) Systemic sepsis 1b) Decubitus Ulcers and Bronchopneumonia 1c) End of Life Skin Changes and Immobility
Conclusion: Natural causes

Cause of death: 1a) The combined effects of myocardial fibrosis and opioid toxicity 2) Fatty Liver Disease
Conclusion: Narrative Conclusion - Andrew Stevenson sadly died on 08/03/2024 at 7 Firethorne Road Liverpool L26 7XE. Andrew had a history of chronic pain from long standing kidney disease (Loin pain haematuria). Andrew had been found unresponsive in bed and police were satisfied there were no suspicious circumstances surrounding his death. Andrew had a previous history of opioid drug dependence. Andrew had an enlarged heart, this is probably due to what is known as obesity cardiomyopathy, there was also evidence on post mortem of previous cardiac damage. The pathologist opined it was the combined effects of heart disease and opioid toxicity which depresses the respiratory system that caused the death of Andrew. Liver disease also contributed to Andrew's death.

Cause of Death: Accidental Choking Episode
Conclusion: Accident

Cause of Death: 1) Aspiration Pneumonia 1b) Pharyngeal dysphagia of unknown aetiology 2) Recent fall with long lie Frailty
Conclusion: Narrative Conclusion - Roy Hartley sadly died on 04/05/2024 at Southport Hospital Merseyside PR8 6PN. Roy's otherwise natural death was contributed to, but not caused by a fall he suffered on about 17/03/2024, he was subsequently found on the floor and admitted to hospital on 23/03/2024 . Even though Roy had all appropriate care and treatment in hospital his condition deteriorated and he passed away peacefully.

Cause of Death: 1a) Unascertained due to decomposition
Conclusion: Narrative Conclusion - Pauline Doran was sadly found deceased on 15/04/2024 at 32 Mildmay Road Bootle Merseyside L20 5EN. Pauline had a medical history of malignant neoplasm of the uterus for which she had surgery in July 2023. Pauline was discovered deceased in her home in an advanced state of decomposition and police were satisfied there was no third party involvement in her death.

Cause of Death: 1a) Congestive cardiac failure 1b) Mixed Aortic Valve Disease 2) Fracture neck of femur (operated), Frailty
Conclusion: Narrative Conclusion - Samuel Joseph Chapman sadly died on 30/04/2024 at Whiston Hospital Merseyside. Samuel died from naturally occurring heart disease, but his death was contributed to by his frailty and a fracture to his hip (Samuel suffered with osteoporosis) that had been operated on following an unwitnessed fall/collapse on the ward when he had attempted to take himself to the toilet.

Cause of death: 1a) Respiratory Failure/Arrest 1b) Aspiration of secretions 1c) Dysphagia and dysarthria 2) Severe Left Ventricular Failure, Atrial Fibrillation, Hypertension, Ruptured Aortic Aneurysm (2014), Chronic Kidney Disease (stage 3) with a single functioning kidney (2017), Covid, Pulmonary Embolism, Heart failure, Idiopathic Hyperkinetic Movement Disorder, Frailty, Immunocompromised state
Conclusion: Natural causes

Cause of Death: 1a) Frailty of Old Age and Alzheimer's Disease 2) Fracture femur right side, Cerebrovascular event
Conclusion: Narrative Conclusion - Diana May Darby sadly died peacefully in receipt of end of life care on 28/04 2024 at Warren Park Nursing Home Blundell sands L23 6UG. Diane died from natural causes, progression of the dementia from which she suffered and frailty associated with her longevity but her death was also contributed to by both a naturally occurring disease process and an unnatural event (fracture to the right hip).

Cause of Death: 1a) Acute myocardial insufficiency 1b) Hypertrophic heart disease and mixed drug use 2) Multiple sclerosis and Crohn's disease
Conclusion: Narrative Conclusion - Laura Eva Dunleavy sadly died on 01/03/2024 at 5 Victoria Place St Helens L35 0LA. Laura had a significant number of serious clinical problems, she was believed to have been experiencing increased pain prior to her death. Toxicological examination of her blood was positive for recent alcohol, cocaine and morphine use, all three of which can increase the risk of a serious cardiac event.

Cause of Death: 1a) Frailty Of Old Age, 2) Clavicle fracture, Atrial Fibrillation
Conclusion: Narrative Conclusion - Pauline Roughley sadly died on 21/07/23 at Whiston Hospital Merseyside. Pauline who was 97 years of age at the time of her death was admitted to hospital on 13th May 2023 with a history of falls and frailty.

Pauline had a significant number of underlying clinical co-morbidities including, atrial fibrillation, hypertension (with postural hypotension), type 2 diabetes mellitus, transient ischaemic attack and a right sided cerebral infarction in May 2020 (stroke).

Pauline was admitted via AED where a stroke was excluded, and Pauline was subsequently admitted to the frailty unit. In hospital Pauline had a chest Xray on 14th May, the clinical history was noted as ? consolidation, crackles present with episode of confusion. On Xray reported on 19/05/2023 it was noted Pauline had to two fractured ribs with no pneumothorax. The age of the fractures was unknown.

The plan was to maximise Pauline’s condition/ability on the rehabilitation unit and to prepare for her discharge, with appropriate support.

However, in the early hours of 10/06/2023 Pauline fell or collapsed while in the toilet. Following the fall/collapse a limited range of movement was noted to Pauline’s right shoulder. A CT scan of Pauline’s head showed no acute intracranial pathology. A shoulder Xray showed a fracture to the right clavicle. On 22/06/23 the orthopaedic team reviewed Pauline’s clavicle, no further treatment was required, and the sling could be worn as desired for comfort.

At the time when Pauline fell/collapsed, she was in receipt of supplementary care and she should have been supervised by a nurse/HCA at all times, but Pauline was left unsupervised for a very short period when the member of staff went to retrieve essential personal items and when she returned, Pauline had either fallen or collapsed sustaining a fracture to her clavicle.

Pauline’s already frail condition began to decline and on or about 07/07/2023, Pauline appeared to be approaching the end of her life, palliative care was subsequently commenced on 10/07/2023.

Pauline’s condition continued to deteriorate, and she passed away peacefully in the presence of her son and daughter in law on 21/07/2023.

Cause of Death: 1a) alcohol intoxication and fatty liver disease 2) ischaemic heart disease
Conclusion: Natural causes

Cause of Death: 1a) Traumatic Subdural Haematoma 1b) Fall 2) Frailty
Conclusion: Misadventure

Cause of Death: 1a) Hospital Acquired Pneumonia 2) Neck of Femur Fracture
Conclusion: Misadventure

Cause of death: 1a) Septicaemia 1b) Abscess of Thumb and Skin Breakdown 1c) Accidental Mechanical Fall 2) Alzheimers disease
Conclusion: Misadventure

Cause of death: 1a) Pneumonia 1b) Aspiration of Gastric Content 1c) Mixed Overdose 2) Bipolar disorder, chronic pain
Conclusion: Suicide  

Cause of death: 1a) Pneumonia 2) Previous traumatic subarachnoid haemorrhage, Facial fractures, Covid-19
Conclusion: Misadventure

Cause of Death: Multiple Injuries
Conclusion: Suicide

Cause of Death: 1a) Malignant Mesothelioma 2) ischemic heart disease, Prostate Cancer
Conclusion: Industrial disease

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Multiple Injuries
Conclusion: Suicide

Cause of Death: 1a) Perforation of small bowel 1b) Meckels diverticulum 2) Fall
Conclusion: Natural causes

Cause of Death: 1a) The toxic effects of heroin/morphine
Conclusion: Drug related

Cause of Death: 1a) Sacrococcygeal Osteomyelitis, Pneumonia 1b) Diabetes mellitus
Conclusion: Natural causes

Cause of Death: 1a) Cellulitis of Lower Limb 2) Frailty
Conclusion: Natural causes

Cause of death: 1a) Combined drug toxicity 2) Pulmonary emphysema
Conclusion: Drug related

Cause of Death: 1a) Necrotising Fasciitis 1b) Operation for Dynamic Hip Screw 1c) Fracture of the neck of the left femur 2) Type 3c Diabetes Mellitus, Iliac artery aneurysm
Conclusion: Accident

Cause of Death: 1a) Heart failure 1b) Ischaemic heart disease 2) Vascular dementia, right neck of femur fracture
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall in care home.

Cause of death: 1a) Hypoxic brain injury 1b) Inhalation Of Toxic Gas (Helium)
Conclusion: Narrative Conclusion - Daniel Leonard Harrington Beevers sadly died on 14/02/2024 at 146 Boode Croft Liverpool L28 4EH. Daniel had a medical history of anxiety and depression, including self harm, he had been suffering with mental health problems for a number of years. Daniel was found deceased with a bag over his head connected to a helium gas cannister. Helium is a toxic gas which can lead to hypoxic brain injury and death. Daniel took his own life but on balance it is not known what his intention was i.e. whether he intended to take his own life.

Cause of death: 1a) Mixed Drug Toxicity
Conclusion: Drug related

Cause of death: 1a) Unascertained
Conclusion: Narrative Conclusion - Craig James Waugh was sadly found deceased on 18/02/2024 at 77 Hall Street St Helens WA10 1EJ. The day before Craig was discovered deceased in his home he was known to be alive at 09.00 hours. Craig had a past medical history of sleep apnoea and asthma. Police found a number of syringes believed to be steroids and two insulin pens, one of which was out of date. It was understood Craig was also a user of Cocaine. The pathologist was unable to ascertain the cause of Craig's death, even though Insulin, steroids and cocaine use can all cause/contribute to death, there was insufficient evidence for the pathologist to make a finding that they had caused/contributed to death nor were any natural causes of death found.

Cause of death: 1a) Intracranial Haemorrhage and Skull Fracture 1b) Head Injury
Conclusion: Accident

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Pulmonary Fibrosis and Fractured Neck of Femur 1c) Systemic Sclerosis and Chronic Alcohol Abuse
Conclusion: Narrative Conclusion - David Bennett sadly died on 04/04/2024 at Southport Hospital PR8 6PN. David was admitted to hospital following a fall in the community on 28/02/2024. David underwent orthopaedic surgery on 29/02/2024, however, David, who had serious underlying health conditions had an eventful post operative period, he was admitted into intensive care and received all appropriate medical treatment. Notwithstanding all appropriate treatment in hospital, David's condition continued to deteriorate culminating in his death.

Cause of death: 1a) Head injury
Conclusion: Accident

Cause of death: 1a) Frailty Of Old Age 2) Multiple fractures due to fall
Conclusion: Narrative Conclusion - John Topping sadly died on 03/04/2024 at Whiston Hospital Merseyside L35 5DR. John was admitted to hospital on 25/03/2024 after sustaining multiple fractures following an unwitnessed fall. John had a significant number of serious underlying conditions including bowel and prostate cancer. John did not have the physiological reserve to recover from his injuries and he died peacefully in hospital. The fractures contributed to, but were not the main cause of John's death.

Cause of death: 1a) Chest infection 1b) Frailty 2) Traumatic Cervical Spinal Cord Injury
Conclusion: Narrative Conclusion - William Edward Carter sadly died on 10/03/2024 at Southport Hospital PR8 6PN. William's otherwise natural cause of death was contributed to by a traumatic injury to his cervical spinal cord sustained when he was involved in a road traffic collision. William was transferred to the North West Regional Spinal Injuries Centre at Southport hospital on 19/10/2023 for rehabilitation.

Cause of death: 1a) Cardiogenic shock 1b) Pulmonary Oedema 1c) Acute myocardial infarction 2) Hypertension, type 2 diabetes mellitus, chronic kidney disease
Conclusion: Natural causes  

Cause of death: 1a) Multiple organ failure 1b) Faecal peritonitis 1c) Ischaemic bowel
Conclusion: Narrative Conclusion - Pamela Joy Lyon sadly died after being admitted to hospital for an elective hysterectomy and partial omentectomy which she had performed on 14/03/2023. During the elective procedure an injury was caused to Pamela’s bowel/the mesentery. Pamela’s deteriorating, grave condition was not recognised as such until matters were escalated by a Registrar and Critical Care also became involved in Pamela’s care on 21/03/2023. A CT scan (abdomen) on 21/03/2023 was highly suggestive of injury to the bowel and consequently Pamela was returned to theatre at c.16 00 hours on 21/03/2023, she was critically unwell. Pamela had four quadrant peritonitis, and a gangrenous distal ileum, she required stoma formation and an appendicectomy. The mesentery was found to be injured which adversely affected the blood flow to the bowel which led to bowel injury/ischaemia and there was a perforation to the affected area of bowel which led to faecal peritonitis. Notwithstanding all appropriate care and treatment in theatre (2nd occasion) and in critical care (from 21/03/2023 after theatre) Pamela’s critical condition deteriorated further leading to multi organ failure and death. Notwithstanding bowel/mesenteric injury are recognised potential complications of such surgery, clinical staff (1) failed to identify in a timely manner that Pamela was becoming critically unwell and that her condition was deteriorating, they (2) failed to escalate to the appropriate senior clinician/s the fact that her condition was deteriorating, in a timely manner (3) they failed to perform an abdominal CT scan on about 18/03/2023, when the diagnosis (abdomen) would probably have been made, (4) they failed to escalate low sodium levels and (5) they failed to (a) diagnose and (b) treat evolving septicaemia in a timely manner or at all as they should have done. The failures identified caused/contributed to the death of Pamela.

Cause of death: 1a) Malignant Mesothelioma
Conclusion: Industrial disease

Cause of death: 1a) Hospital Acquired Pneumonia 2) Fracture neck of femur
Conclusion: Narrative Conclusion - Teresa Doris Henshall sadly died on 30/03/2024 at Whiston Hospital Merseyside L35 5DR. Teresa was admitted to hospital on 15/03/2024 with a fracture to her hip. Teresa had a number of serious underlying health problems. Not withstanding all appropriate care and treatment in hospital Teresa's condition deteriorated culminating in her death from Pneumonia.

Cause of death: 1a) Cardiac Failure 1b) Aortic and Mitral Valve incompetency 1c) Infective endocarditis 2) Intravenous drug use
Conclusion: Narrative Conclusion - Michaela Elizabeth Wycherley sadly died at Whiston Hospital Merseyside L35 5DR on 09/02/2024. Michaela was admitted to hospital on 04/02/2024, her grave condition was unsuitable for surgery and notwithstanding all appropriate care and treatment in hospital Michaela's condition deteriorated culminating in her death.

Cause of death: 1a) The combined effects of Myocardial Fibrosis, Fatty Liver Disease and Morphine Toxicity
Conclusion: Narrative Conclusion - Robert Stephen Langtree was sadly found deceased on 25/01/2024 at 5 Holbrook Close St Helens Merseyside WA9 3XH. Police were satisfied there was no third party involvement in the death of Robert, which was caused by a combination of excessive opioid medication found on toxicological analysis of his blood, heart and liver disease.

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Stroke 1b) Atrial Fibrillation, Type 2 Diabetes 2) Hypertension
Conclusion: Narrative Conclusion - Eileen Ireland was admitted to hospital on 14/04/2023 having suffered a significant stroke from which she was unable to recover. Eileen had been discharged from hospital to her care home on 17/02/2023, because Eileen had Atrial Fibrillation, she was prescribed Edoxaban, to prevent stroke, however, because the medication discharge documentation completed by a doctor, noted incorrectly that Eileen was allergic to Edoxaban, and the hospital pharmacist did not notice this error, it wasn’t administered at all by the care home because they believed they had been informed not to give it due to the risk from an allergic reaction. Following a brief admission on about 15/03/2023 Eileen was discharged the same day, with no changes to her medication, consequently the error and the fact Eileen was not receiving Edoxaban was not identified. The hospital understood she was receiving it as prescribed. On balance, the omission of the administration of Edoxaban that was multifactorial caused the stroke that led to the death of Eileen Ireland.

Cause of death: 1a) Urinary sepsis 2) Malnutrition and Self Neglect, Acute Kidney Injury, Ischaemic heart disease, Chronic Obstructive Pulmonary Disease, Depression
Conclusion: Narrative Conclusion - Natural cause contributed to by self-neglect.

Cause of death: 1a) Traumatic Head and Chest Injuries
Conclusion: Accident

Cause of death: 1a) Mixed Drug Toxicity
Conclusion: Drug related

Cause of Death: 1a) Pneumonia 1b) Fractured neck of femur 1c) Fall
Conclusion: Accident

Cause of Death: 1a) Pneumonia and Hepatic Failure 2) recent cerebral injury, Hepatic cirrhosis
Conclusion: Misadventure

Cause of Death: 1a) Pneumonia 2) Fracture of left neck of femur, Frailty of old age
Conclusion: Misadventure

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Hospital Acquired Pneumonia 1b) Right pubic ramus fracture
Conclusion: Misadventure

Cause of Death: 1a) Acute myocardial insufficiency 1b) Mixed Drug Toxicity and Cardiac Fibrosis
Conclusion: Drug related

Cause of death: 1a) Multi organ failure 1b) Caecal perforation and small bowel perforation
Conclusion: Natural causes

Cause of death: 1a) Fatty Liver and Amphetamine Toxicity
Conclusion: Alcohol and Drug related

Cause of death: 1a) Multi-organ failure 1b) Pneumonia 2) Drug misuse
Conclusion: Narrative Conclusion - Grainne Michelle Hussey sadly died on 26/12/2023 at Southport Hospital PR8 6PN. Grainne was taken to hospital after calling paramedics and informing them that she had taken a deliberate overdose of various medications 48 hours previously including Co-Codamol, Pregabalin, and Mirtazapine. Grainne had a previous history of intentional overdose, Grainne was admitted to critical care however, her condition rapidly deteriorated. On admission to hospital Grainne had a chest infection, which can precipitate respiratory depression, the additional use of medications/drugs added to the morbidity and rapid clinical decline, which resulted in the death of Grainne. The cause of Grainne's death was natural, it was however contributed to by drug/medication misuse. Even though Grainne told paramedics that she had taken an intentional overdose some 48 hours previously, it cannot be found on balance that even though she took the tablets that contributed to her death, she intended to take her own life (that was not found).

Cause of death: 1a) Lower respiratory tract infection 2) Frailty, Recent Hemiarthroplasty Right Hip
Conclusion: Narrative Conclusion - Margaret McWilliams Fitzpatrick sadly died on 09/03/2024 at Southport Hospital Town Lane Southport PR8 6PN. Margaret who was 98 years of age was extremely frail and this frailty and recent hip surgery which was necessary following a fall sustained outside of hospital contributed to but did not cause her otherwise natural cause of death.

Cause of death: 1a) Congestive cardiac failure, Pneumonia 2) Ischaemic heart disease, Chronic Obstructive Pulmonary Disease, Frailty, Acetabular fracture
Conclusion: Narrative Conclusion - Raymond Thomas Poar sadly died on 07/03/2024 at Whiston Hospital Merseyside. Raymond died from a natural cause of death, but one of the contributing causes (Acetabular Fracture) was unnatural caused when Raymond suffered from a fall. Raymond suffered a fall at home prior to admission but he also suffered from another two falls in hospital, the fracture was probably sustained following the second in patient fall.

Cause of death: 1a) Community Acquired Pneumonia 1b) Acute Covid Infection 2) Pulmonary fibrosis, Asbestosis
Conclusion: Narrative Conclusion -  Christopher Reginald Lee sadly died at home in the presence of his family on 02/03/2024 at 115 Sandbrook Road Southport Merseyside PR8 3JF. Christopher was cared for on the end of life pathway to ensure he was peaceful and pain free at the end of his life. Pulmonary fibrosis and asbestosis contributed to the death of Christopher but they did not cause it, it was caused by naturally occurring disease i.e. Acute Covid Infection and Community Acquired Pneumonia. Christopher was discharged from hospital on 26/02/2024 for end of life care, he also had a significant number of underlying clinical co-morbidities. In life it is understood Christopher who was a retired joiner had come into contact with asbestos, including cutting sheets of asbestos. Christopher had been in receipt of Industrial Injuries Disablement benefit in respect of Pneumoconiosis with Asbestosis.

Cause of death: 1a) Drowning 1b) The Effects of Alcohol and Cocaine Use
Conclusion: Alcohol and Drug related

Cause of death: 1a) Drowning
Conclusion: Accident

Cause of death: 1a) Fracture of right hemi sacrum 1b) Fall 1c) Frailty 2) Dementia, anaemia
Conclusion: Narrative Conclusion - Doreen who was extremely frail and who also suffered from dementia, was admitted to hospital following a fall in her nursing home, she had suffered no acute head/brain injury. Doreen had sustained fractures in her pelvic region, however, she fell again in AED where she also sustained a fracture inter alia to her right hemisacrum, which caused/contributed to her death which was also contributed to by her frailty, anaemia and dementia. Doreen’s Xray also showed a demineralised skeleton. If Doreen had received supplementary care in AED as she should have done, then the fall in AED would probably have been prevented.

Cause of Death: 1a) Frailty Of Old Age 2) Sub-dural haematoma, Advanced dementia, chronic kidney disease, Cardio Vascular Accident
Conclusion: Narrative Conclusion - Natural Causes contributed to by the effects of an earlier unwitnessed fall at home.

Cause of Death: 1a) Metastatic prostate cancer and advanced frailty 2) Osteoporosis, Atrial fibrillation, Fracture neck of right femur (operated)
Conclusion: Natural causes

Cause of death: 1a) Mixed drug and alcohol toxicity
Conclusion: Alcohol and Drug related

Cause of death: 1a) Pneumonia 2) Emphysema, Cocaine Use
Conclusion: Drug related 

Cause of death: 1a) Pneumonia and methadone toxicity 2) Alcohol Induced Fatty Liver Disease
Conclusion: Alcohol and Drug related

Cause of death: 1a) Pneumonia 2) Traumatic Subdural Haemorrhage, Frailty of Old Age
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall at home.

Cause of death: 1a) Multi-organ failure 1b) Chest, abdominal and leg trauma 1c) Motorcycle driver in a vehicular collision
Conclusion: Road Traffic Collision

Cause of death: 1a) Pulmonary embolism 1b) Deep vein thrombosis 1c) Fracture Right Tibia
Conclusion: Accident

Cause of death: 1a) Pneumonia 2) Stage 4 lung cancer, Neck of femur fracture - operated on
Conclusion: Natural causes

Cause of death: 1a) Hypoxic brain injury 1b) Out of Hospital Cardiac Arrest 1c) Choking on food bolus 
Conclusion: Accident

Cause of death: 1a) Respiratory arrest 1b) Traumatic brain injury
Conclusion: Road Traffic Collision  

Cause of Death: 1a) Cardio- Respiratory Arrest 1b) Aspiration Pneumonia 2) Atrial Fibrillation, Cerebral Vascular Accident (pre-existing)
Conclusion: Natural causes

Cause of death: Acute Opiate (morphine/Heroin) Toxicity
Conclusion: Drug related

Cause of death: 1a) Hanging
Conclusion: Suicide 

Cause of death: 1a) Mixed Drug Overdose 2) Cirrhosis
Conclusion: Drug related

Cause of death: 1a) Aspiration Pneumonia 2) Covid 19, Bilateral subdural haematomas, Frailty
Conclusion: Misadventure

Cause of death: 1a) The toxic effects of dihydrocodeine
Conclusion: Drug related

Cause of death: 1a) Myocardial fibrosis 1b) Cocaine misuse
Conclusion: Drug related

Cause of Death: 1a) Subdural Haemorrhage 2) cerebral atrophy
Conclusion: Natural causes

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Mixed Drug Toxicity
Conclusion: Drug related

Cause of Death: 1a) Unascertained
Conclusion: Open

Cause of Death: 1a) Hospital Acquired Pneumonia 1b) Fracture neck of right femur (operated) 2) Frailty of old age
Conclusion: Accident

Cause of Death: 1a) Frailty Of Old Age 2) Fracture Pelvis (on Anticoagulants)
Conclusion: Natural causes

Cause of Death: 1a) An incised wound to the right wrist
Conclusion: Alcohol related

Cause of Death: 1a) Malignant Mesothelioma 1b) Asbestos exposure
Conclusion: Industrial disease

Cause of Death: 1a) Paracetamol Overdose 2) Ischaemic heart disease, Chronic kidney disease stage 4, Frailty of old age
Conclusion: Suicide

Cause of Death: 1a) Unascertained
Conclusion: Open

Cause of Death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of Death: 1a) Bronchopneumonia 1b) C5 level Complete traumatic tetraplegia (Fall at home on 08/02/2024) 1c) Congestive cardiac failure 2) Acute respiratory failure
Conclusion: Misadventure

Cause of Death: 1a) Frailty Of Old Age 2) Multiple rib fracture, periprosthetic right hip fracture, Pneumohemothorax.
Conclusion: Misadventure

Cause of Death: 1a) Malignant peritoneal mesothelioma 1b) Pleural plaques secondary to asbestos exposure 2) Heart failure, Ischaemic heart disease
Conclusion: Industrial disease

Cause of Death: 1a) Multiorgan Failure 1b) Cocaine Toxicity
Conclusion: Drug related

Cause of Death: 1a) Community acquired pneumonia 1b) Fracture neck of femur 1c) Fall 2) Heart failure, Chronic kidney disease stage 3
Conclusion: Narrative Conclusion - Doreen Walsh died when having been admitted to hospital following a fall at home, she had a further fall on the ward on 14/02/2023, the fall was unwitnessed. Doreen was not in receipt of 1-1 care as she should have been, she was not examined by a doctor as she should have been and the Xray that should have been undertaken was not undertaken until 17/02/2023. Doreen was not well enough to withstand surgery for the fracture, her condition deteriorated, and she was commenced on end-of-life care.  

Cause of Death: 1a) Multiple organ failure 1b) Ischaemic Small Bowel 1c) Small Bowel Obstruction
Conclusion: Natural causes

Cause of death: 1a) Drowning
Conclusion: Accident

Cause of death: 1a) Lower limb ischaemia 1b) Peripheral vascular disease 1c) Type 2 diabetes mellitus 2) Fractured neck of femur (operated), Alzheimer's
Conclusion: Misadventure

Cause of death: 1a) Sepsis of Unknown Origin 1b) Bilateral femur fractures 2) Epilepsy, Dementia, Acute kidney injury
Conclusion: Misadventure

Cause of death: 1a) Multi organ failure 1b) Gastrointestinal bleeding 1c) Decompensated liver disease, gastric by-pass 2) Rheumatoid arthritis
Conclusion: Narrative Conclusion - Mrs Hatch died at Whiston Hospital on 1st July 2023 having developed multi-organ failure due to known and recognised complications of surgery initially performed on 6th January 2023 when an omental patch had been placed over an anastomotic ulcer.

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Severe left ventricular hypertrophy 1b) Drug (cocaine) misuse and fatty liver
Conclusion: Natural causes

Cause of death: 1a) Infective endocarditis and Spondylodiscitis with Epidural Abscess 1b) Transcatheter aortic valve implantation 1c) Aortic valve disease
Conclusion: Misadventure

Cause of Death: 1a) MDMA (ecstasy) and Caffeine Toxicity
Conclusion: Misadventure

Cause of Death: 1a) Infective exacerbation of chronic obstructive pulmonary disease 2) Methadone toxicity
Conclusion: Drug related

Cause of Death: 1a) Infective endocarditis 1b) Intravenous Drug Abuse 2) St Elevation Myocardial Infarction
Conclusion: Drug related

Cause of Death: 1a) Aspiration Pneumonia 1b) Acute Subdural Haemorrhage 2) Atrial Fibrillation, Previous Pulmonary Embolism
Conclusion: Misadventure

Cause of Death: 1a) Suspension by ligature
Conclusion: Suicide

Cause of Death: 1a) Acute airway obstruction 2) Frailty, Influenza
Conclusion: Misadventure

Cause of Death: 1a) Hypovolaemic shock 1b) Post-operative haemorrhage 1c) Adenocarcinoma of the Rectum
Conclusion: Natural causes

Cause of Death: 1a) Unascertained due to decomposition
Conclusion: Open

Cause of Death: 1a) Acute myocardial infarction, Pneumonia 2) Mixed Drug Toxicity
Conclusion: Narrative Conclusion - Ms Costello died on 13th November 2023 from natural causes but her death was precipitated by her recent ingestion of a cocktail of drugs contributing to respiratory failure.

Cause of Death: 1a) Hospital Acquired Pneumonia 1b) Ischaemic cerebrovascular accident 1c) Anastomotic Leak (operated) 2) Frailty, Rectal cancer (operated)
Conclusion: Narrative Conclusion - Mr Vaughan died at Whiston Hospital on 2nd November 2023 as a result of known and recognised complications of elective surgery of an anterior resection for a distal neoplasm which resulted in an anastomotic leak on 28th September 2023.

Cause of Death: 1a) Acute myocardial insufficiency 1b) Severe coronary artery atheroma 2) Anabolic Steroid Use
Conclusion: Natural causes

Cause of death: 1a) Multi-organ failure 1b) Aspiration Pneumonia 2) Total Hip Replacement, Pulmonary Embolism
Conclusion: Narrative Conclusion - Malcolm Edward Gregson sadly died on 24/01/2024 at Southport Hospital Merseyside PR8 6PN. Malcolm had a total hip replacement on 02/12/2023, after which he received anticoagulant therapy. On 09/12/2023 Malcolm attended AED due to having difficulty breathing. Malcolm was seriously unwell, he developed inter alia pleural empyema and he was appropriately aggressively medical treated/managed. However, Malcolm's condition continued to deteriorate culminating in his death.  

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Traumatic Bilateral Subdural Haematoma
Conclusion: Narrative Conclusion - John Szaloky sadly died on 20/01/2024 at Whiston Hospital Merseyside L35 5DR. John sustained catastrophic traumatic bilateral subdural haematomas when he fell, necessitating surgery at the neurosurgical hospital on 08/10/2023. Notwithstanding all appropriate medical management and treatment John's condition deteriorated culminating in his death.

Cause of death: 1a) Frailty Of Old Age 2) Subarachnoid Haemorrhage, Distal tibia-Distal Fracture, Pulmonary Embolism, Atrial Fibrillation, and Dementia
Conclusion: Narrative Conclusion: Yvonne Anne Hunter sadly died on 17/01/2024 at Elm House Nursing Home, 43 Cambridge Road, Southport, Merseyside. Yvonne had suffered a fall in November 2023 when she sustained a number of serious injuries and associated medical problems, from which she was unable to recover and which, notwithstanding all appropriate care and treatment contributed to her death.

Cause of death: 1a) Bronchopneumonia, Mixed Drug Use 2) Emphysema, Chronic kidney disease
Conclusion: Narrative Conclusion - Regginald Aitchison sadly died on 10/12/2023 at Whiston Hospital Merseyside L35 5DR. Regginald died from a combination of a natural (bronchopneumonia) and unnatural (Mixed Drug Use) cause of death which was contributed to by two serious underlying clinical conditions. Regginald had a previous medical history which included illicit drug use and at the time of death there was evidence of recent excessive cocaine use as well as a number of other drugs many of which cause central nervous system and respiratory depression.

Cause of death: 1a) Multi-organ failure 1b) Opioid toxicity and infective exacerbation of chronic obstructive pulmonary disease 2) Osteoporosis and spinal stenosis
Conclusion: Narrative Conclusion - Susan Jayne Graham sadly died on 13/01/2024 at Southport Hospital Merseyside. Susan had serious underlying health problems, which can be very painful, for which she had been prescribed and taken opioid analgesia. Opioid analgesia can cause respiratory failure if taken in excess, even inadvertently. Prior to her admission to hospital Susan had taken Oramorph analgesia which had been prescribed, she was subsequently found unresponsive and was taken to hospital on 09/01/2024, where notwithstanding all appropriate medical care and treatment her condition deteriorated leading to her death.

Cause of death: 1a) Multi organ failure 1b) Proteus Mirabilis septicaemia 1c) Infected Pressure Ulcer of the Right Heal 2) Insulin Dependent Diabetes Mellitus, Congestive Cardiac Failure
Conclusion: Natural causes 

Cause of Death: Severe head injuries
Conclusion: Narrative Conclusion - Rebecca Aimee Cooke was out for a brief lunch time walk when she was the innocent victim involved in a road traffic collision (RTC) which occurred on the pavement. Rebecca was hit by a motorcycle, being driven at high speed and catastrophically injured. As a direct consequence of the injuries she sustained, tragically Rebecca died in hospital two days after the collision (03/03/2021).

Cause of Death: 1a) Venlafaxine and Promazine Toxicity
Conclusion: Drug related

Cause of Death: 1a) Hospital Acquired Pneumonia 1b) Intracranial Haemorrhage 1c) Intracranial Haemorrhage
Conclusion: Accident

Cause of Death: 1a) Aspiration Pneumonia 1b) Traumatic subarachnoid haemorrhage
Conclusion: Accident

Cause of Death: 1a) Mixed Drug Use 2) Fatty Liver Disease
Conclusion: Drug related

Cause of Death: 1a) Traumatic Intracerebral Bleed 1b) Collapse leading to falls 1c) Sepsis 2) Mechanical Aortic Valve replacement, High International Normalised Ratio on admission, Ischaemic heart Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Heart Block.
Conclusion: Narrative Conclusion - On 22/12/2022 James Arnold Kendrick was admitted to hospital with chest pain and fever, he was diagnosed and treated for sepsis, Arnold’s INR had been very high, but it was appropriately managed as was his medical care. On 23rd & 24th December Arnold had two episodes of collapse which led to him falling to the ground on the ward and sustaining preventable traumatic intracerebral injuries the second of which was catastrophic and led to Arnold’s death.

The nursing staff failed to properly assess and manage the falls risk’s Arnold faced. The two falls that arose from episodes of collapse were both (on balance) preventable.

Cause of death: 1a) Acute alcohol intoxication 2) Fatty Liver Disease
Conclusion: Alcohol related

Cause of death: 1a) Community Acquired Pneumonia 1b) Fracture of Multiple Ribs and T12 1c) Fall
Conclusion: Accident

Cause of death: 1a) Traumatic Subdural Haemorrhage
Conclusion: Accident

Cause of death: 1a) Codeine Toxicity 2) Alcohol Induced Fatty Liver Disease
Conclusion: Alcohol and Drug related 

Cause of death: 1a) Intracranial Haemorrhage 2) Fracture neck of femur (operated)
Conclusion: Accident

Cause of death: 1a) Hanging
Conclusion: Suicide

Cause of death: 1a) Hanging
Conclusion: Suicide 

Cause of death: 1a) Multiple organ failure 1b) Acute Fulminant Hepatic failure 1c) Paracetamol Overdose 2) Cerebrovascular Disease, Left Ventricular Systolic Dysfunction
Conclusion: Drug related

Cause of death: 1a) Aspiration Pneumonia 2) Paracetamol toxicity, Parkinsons Disease
Conclusion: Narrative Conclusion - Philip died after taking an intentional overdose of a significant number of paracetamol tablets c100, which led to Philip becoming drowsy/with a reduced level of consciousness at home prior to admission to hospital. The concentration of paracetamol in Philip’s blood was excessive but the timely administration of N Acetyl Cystine prevented liver damage. Both Paracetamol toxicity as well as a background history of Parkinson's disease were major risk factors for drowsiness/reduced level of consciousness.

Reduced consciousness causes the throat muscles to relax, suppressing the natural cough reflex and ability to keep the airway clear, increasing the risk of aspiration pneumonia. Aspiration pneumonia which caused Philip’s death can, due to the changes in the lungs that follow, lead to sudden death. Both the paracetamol overdose and Parkinson’s disease contributed to the death of Philip.

Cause of death: 1a) Multiple Injuries
Conclusion: Suicide

Cause of Death: 1a) Multi organ failure 1b) Intestinal Ischaemia 1c) Intestinal Obstruction due to Codeine ( Operated) 2) Hypertension, Chronic kidney disease
Conclusion: Narrative Conclusion - David Thomas Aspinall sadly died on 20/12/2023 at Whiston Hospital Merseyside. David was admitted to hospital on 18/12/2023 with an intestinal obstruction probably caused by unintentional codeine medication excess, which David had been taking for neck pain. David underwent an essential laparotomy with sub total colectomy due to the bowel ischaemia that was found. However, notwithstanding all appropriate care and treatment in hospital David's condition deteriorated culminating in his death.

Cause of Death: 1a) Pneumonia 1b) Rib fracture 1c) Mechanical Fall
Conclusion: Accident

Cause of Death:  1a) Multi-organ failure 1b) Fracture neck of femur 2) Chronic kidney disease, Type 2 diabetes mellitus, Hypertension
Conclusion: Accident

Cause of Death: 1a) Colitis and Myocarditis 1b) Immunotherapy for Melanoma 1c) Metastatic Melanoma 2) Ulcerative Colitis
Conclusion: Narrative Conclusion - William Peter Birch sadly died on 14/10/2023 at Queenscourt Hospice Southport PR8 6RE. William necessarily underwent immunotherapy to help to treat/slow the spread of the metastatic melanoma with which he had been diagnosed. The recognised side effects of the immunotherapy led to the two conditions that ultimately caused the death. William died peacefully in the hospice in the presence of his wife.

Cause of Death: 1a) Acute on chronic subdural haemorrhage 1b) Falls 1c) Parkinson's Disease and Postural Hypotension
Conclusion: Narrative Conclusion - William John Thompson sadly died on 27/12/2023 at Southport Hospital PR8 6PN. William who also had a medical history of prostate cancer in addition to a significant number of medical co-morbidities was admitted to hospital following a fall at his home on 19/10/2023 and he was discharged on 15/11/2023. William was admitted to hospital again on 10/12/2023, William was becoming increasingly frail and not withstanding all appropriate care and treatment in hospital his condition deteriorated culminating in his death.

Cause of Death: 1a) Bronchopneumonia 2) Combined drug toxicity
Conclusion: Narrative Conclusion - Steven Dennis McGlue sadly died on 02/11/2023 at 2 Redgate Drive St Helens Merseyside WA9 1RQ. Steven who had felt unwell for about a week prior to his death died from a naturally occurring disease process, but his death was contributed to by a combination of drugs. Police were satisfied there were no suspicious circumstances surrounding Steven's death.

Cause of Death: 1a) Pulmonary Embolus 1b) Bowel Cancer
Conclusion: Narrative Conclusion - Stephen John McGrady sadly died on 04/01/2023 at Whiston Hospital Merseyside. Stephen was taken to hospital in cardiac arrest, he had complained of pain in his left calf earlier in the day.

Background

Stephen had been admitted to hospital with appendicitis 03/07/2022- 05/07/2022 which was managed conservatively.

Stephen was admitted to hospital a second time with similar pain and treated conservatively for appendicitis on 08/09/2022 , Stephen had a C T scan on 10/09/2022 and he was discharged on 12/09/2022. Even though conservative management was reasonable under the circumstances there were missed opportunities to make an earlier diagnosis in particular in respect of the anaemia which can be an indication of the presence of cancer and the mass on CT scan (10/09/22) that was suspicious of cancer.

Surgery

Stephen returned to hospital a 3rd time and he underwent laparoscopic hemicolectomy on 24/09/2022, the mass which was removed completely was found to be an adenocarcinoma for which Stephen also subsequently commenced chemotherapy.

The cancer had not spread to the lymph nodes, nor had it metastasised and the operation on 24/09/2022 was opined to be curative. On balance, even though there were missed opportunities to make an earlier diagnosis, the time from presentation in July to surgery did not adversely affect the outcome and the surgery was curative.

Chemotherapy

Notwithstanding the risks associated with chemotherapy, Stephen weighed up those risks with the doctor and he subsequently commenced chemotherapy.

On 30th December 2022 Stephen attended the chemotherapy centre for cycle 3 of Capecitabine.

The registered nurse who was responsible for assessing Stephen, did not compare Stephen’s abnormal vital signs (with shortness of breath) to his baseline nor did she repeat his observations when his heart rate was raised as she should have done. Stephen was assessed to have grade 1 symptoms. Which meant on the observations taken by the nurse, chemotherapy could still be administered.

Stephen complained of shortness of breath and his heart rate was 109, the nurse assumed it was raised because he had walked down the ward, but because it was not compared with his baseline and because the heart rate was not checked again, as it should have been she was unable to say whether the results would have resulted in escalation or warrant further investigation.

The nurse acknowledged shortness of breath could indicate the possibility of a thromboembolic event, a known risk associated with chemotherapy and cancer patients.

The symptoms (shortness of breath/raised heart rate) being experienced by Stephen were not discussed/raised with the oncologist/escalation nurse as they could have been, if the nurse had wished to use her professional judgement. The nurse told Stephen’s wife, that she would inform the oncologist of Stephen's raised heart rate, but she did not do so, and the oncologist was unaware of this.

In summary, the nurse did not repeat Stephen’s observations as she should have done, she did not compare the observations in particular the raised heart rate (and shortness of breath) with his base line as she should have done, she did not arrange for a 24 hour follow up call as she could have done, she did not informally discuss his case with a senior nurse or doctor as she could have done and she did not tell Stephen or his wife if he experienced calf pain a sign of DVT, that can lead to pulmonary embolism, then he must seek medical advice urgently, even though she was knew of the risks associated with cancer patients, chemotherapy and thromboembolic events.

Because Stephen’s vital signs were not repeated or compared with the baseline observations, it cannot be known if Stephen remained with Grade 1 symptoms and consequently it was appropriate for him to proceed as he did with his chemotherapy, whether his symptoms had settled or whether they had deteriorated, which would have led to escalation and investigations by the oncologist.

Cause of death: 1a) Intra-cranial haemorrhage (subarachnoid and subdural haemorrhage) 1b) Trauma/Fall 2) Community acquired pneumonia, dementia, atrial fibrillation, osteoarthritis
Conclusion: Accident 

Cause of death: 1a) Bronchopneumonia 1b) Congestive cardiac failure 1c) Diabetes type 2 2) Complete Paraplegia at T12 level
Conclusion: Narrative Conclusion - Natural causes contributed to by the effects of an unwitnessed fall at home approximately nine months earlier.

Cause of death: 1a) Orthostatic Pneumonia 1b) Right Fractured Neck of Femur 1c) Unwitnessed fall in care home 2) Atrial Fibrillation, Ischaemic Heart Disease, Dementia
Conclusion: Accident

Cause of Death: 1a) Congestive Cardiac Failure with Fast Atrial Fibrillation
Conclusion: Natural causes

Cause of Death: 1) Multi organ failure 1b) Self Poisoning
Conclusion: Drug related

Cause of death: 1a) Hospital Acquired Pneumonia 1b) Chronic Obstructive Pulmonary Disease 2) Right Hip Fracture, Frailty Of Old Age
Conclusion: Natural causes

Cause of Death: 1a) Multiple Injuries
Conclusion: Suicide

Cause of death: 1a) Subdural haemorrhage (traumatic)
Conclusion: Accident

Cause of Death: 1a) Acute subdural haematoma 1b) Chronic Subdural Haematoma 2) Epilepsy
Conclusion: Misadventure

Cause of Death: 1a) Pulmonary Embolus 1b) Neck of Femur Fracture (Operated) 2) Pneumonia
Conclusion: Misadventure

Cause of Death: 1a) Lung Mesothelioma 2) Congestive Cardiac Failure, Atrial Fibrillation and Chronic Kidney Disease
Conclusion: Industrial disease

Cause of Death: 1a) Paracetamol toxicity
Conclusion: Drug related

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of death: Mixed Drug Toxicity
Conclusion: Drug related

Cause of death: 1a) Opioid toxicity
Conclusion: Drug related

Cause of death: 1a) Unascertained due to decomposition
Conclusion: Open

Cause of death: 1a) Aspiration Pneumonia 1b) Sigmoid Volvulus (operated)
Conclusion: Natural Causes

Cause of death: 1a) Multi-organ failure 1b) Intraabdominal sepsis and acute pancreatitis 1c) Duodenal perforation secondary to endoscopic retrograde cholangiopancreatography (ERCP)
Conclusion: Misadventure

Cause of Death: 1a) Asphyxia by Choking
Conclusion: Accident

Cause of Death: 1a) Mixed Drug (Heroin and Methadone) Toxicity
Conclusion: Drug Related

Cause of Death: 1a) Hanging
Conclusion: Suicide

Cause of Death: 1a) Community Acquired Pneumonia and progression of Mesothelioma
Conclusion: Industrial Disease

Cause of Death: 1a) Pneumonia 1b) Fractured Right Neck of Femur 2) Osteoporosis
Conclusion: Accident

Cause of Death: 1a) Hespatic Failure 1b) Hepatic Cirrhosis 2) Acute Kidney Injury, Neck of Femur Fracure; Surgery
Conclusion: Narrative Conclusion - Mary Teresa Hill sadly died on 14/11/2022 at Whiston Hospital Merseyside. Mary was admitted to hospital on 29/09/2022 with confusion and shortness of breath, she was treated for community acquired pneumonia. On 11/10/2022 Mary had a fall on the ward, she fractured her hip and went to theatre for repair on 14/10/2022. At the time of the fall it was recognised that Mary was at risk of falling and all appropriate falls prevention measures were in place. Mary slipped while taking herself to the toilet unassisted, either because she could not wait for a nurse to arrive to take her or because she felt able to take herself to the toilet, as she had been doing. The nurse responded immediately to Mary’s shouts for help when she had fallen at which time all appropriate clinical action was taken. Mary also had a number of serious underlying clinical conditions. Mary was known to have hepatic cirrhosis, diagnosed on a scan in 2019, this was assumed to be due to a combination of non-alcoholic fatty liver disease, and previous methotrexate induced liver injury, but this was not confirmed by liver biopsy. Mary had not had Methotrexate since 2019 and her liver cirrhosis had been well compensated until her last admission. Mary also developed a significant number of other serious problems during her admission including becoming Covid 19 positive, developing a wound infection, developing heart failure, she had right sided pulmonary embolisms and her stool culture also became positive for clostridium difficile. This combination of appropriately managed, serious, complex clinical problems, including the fracture sustained as an in-patient, necessitating surgery resulted in Mary’s liver decompensating, and notwithstanding all appropriate clinical management of her liver disease, her liver was unable to cope, failed and caused her death.

Cause of Death: 1a) Sepsis 1b) Osteomyelitis 1c) Infected Pressure Sores
Conclusion: Narrative Conclusion - John Patrick McCarthy died of sepsis in hospital which arose from infected pressure sores. John was extremely unwell and received a package of care in the community, prior to his hospital admission. John, who had capacity to make his own decisions, often declined to follow advice that would have been likely to improve his health and pressure areas and would have helped to keep his wounds clean and stop his skin breaking down. John had received appropriate nursing and community care for many months prior to his death, there were some gaps in his care in particular between 25th & 26th October 2022 prior to his last admission to hospital where again he received all appropriate care and treatment until he died peacefully, in receipt of palliative care.

Cause of Death: 1a) Stab wound to the chest.
Conclusion: Narrative Conclusion - Kyle Whitley died following a single stab wound to the chest. Kyle was stabbed in his home; the fatal stab wound punctured his heart and lung. Kyle left his home, after he had been stabbed, but he collapsed in an alleyway close to his home, all appropriate attempts at emergency treatment/resuscitation were unsuccessful. To date, there has not been a prosecution and on the evidence currently available, on the balance of probability Kyle Whitley died as a consequence of the chest (stab) wound, inflicted upon him without justifiable cause.