Coroner's Conclusions

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.