Billy Longshaw

To the Chief Executive, Great Western Hospitals NHS Foundation Trust

1) Notwithstanding Mr Longshaw died within 24 hours of being seen in the Emergency Department at Great Western Hospitals, Swindon, in circumstances where he was permitted to leave without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded, it is a matter of concern that the Trust has not undertaken a detailed investigation into the care and treatment provided to him.

Prompt, rigorous and effective investigations into serious clinical incidents are essential to deriving learning and improving patient safety;

2) The ’48 Hour Report for Significant incidents resulting in Moderate Harm and above’ prepared by an ED Consultant and others is fundamentally and obviously flawed (even when read against the Trust’s own medical records), prefaced as it is by the assumption that ‘the patient self-discharged against medical advice’. The Trust’s (limited) review of this matter represents a missed opportunity to consider vital issues such as the presentation of patients with significant learning disabilities to the Emergency Department, and the practical application of the Mental Capacity Act 2005 in this clinical setting.

To the Chief Executive and Registrar, The General Medical Council

3) Mr Longshaw’s death raises issues as to the adequacy of education provided to medical students as to the Mental Capacity Act 2005, and doctors’ of all levels familiarity with the practical application of this legislation in clinical settings, and accompanying guidance such as that produced by the General Medical Council in this regard.