Jonathan Fry

On the 6th of May 2015 commenced an investigation into the death of Jonathan Lewis aged 58 years. The investigation concluded at the end of the Inquest on the 29th April 2016. The conclusion of the inquest was natural causes_

On the 16th of April 2015 Mr Fry was admitted to the Accident and Emergency Department following an un-witnessed fall: He had a history of low blood pressure and was alcohol dependant with controlled diabetes: He was started on DVT prophylaxis although the probability of a DVT leading to a Pulmonary Embolism (PE) was considered Iow in someone with Chronic Liver Disease_ He was diagnosed with a L1 compression fracture and was referred to the Orthopaedic Team for assessment: He was deemed not to be trauma patient and accordingly was suitable to be admitted into the care of the Medical Team: This did not happen and he remained in the care of the Orthopaedic Team, the plan being that the Medical Team would both assess and advise on Mr Fry's clinical care plan: Mr Fry_ was admitted onto an orthopaedic ward. He did not have either a Fry, senior review which was the practice, by any Consultant at any time from admission to his death the Orthopaedic Consultant was sick with no locum cover ). On the April at 10.25 am Mr had a review by a Medical Registrar and an Orthopaedic SHO. A CT scan ordered of the chest abdomen and pelvis but this did not happen and there was no record that this omission was considered or followed up. In the afternoon of the 17th April Mr was reviewed by orthopaedic SHO. The medical notes are unclear as to what reviews if any were had on the 18th of April. There is no sign of any Medical Team review and although evidence at the Inquest suggested that reviews would have taken place as this was routine. There were entries in the balance chart which suggested some review of Mr Fry's medications had taken place. On the 1gth April there was a SHO review by the Orthopaedic team there is an (untimed ) that a Medical Registrar saw Mr Fry. The Critical Care Outreach Team (CCOT) reviewed Mr Fry at 11.16 as his News Score was scoring a persistent 9
10. A physical examination did not suggest a DVT or PE: His demand for oxygen had risen but he was not in distress and a request for Respiratory Team review was made although this was not possible before his death: The CCOT worker was reassured that the Medical Registrar was there although it transpired he had been called away due to a Cardiac Arrest_ Mr Fry was physically unwell but alert and talking: It was assumed that Mr Fry's oxygen demand had gone up due to the chest infection_ During the afternoon on of the 1gth April his News Score rose to 11 He was seen CCOT at 11.30 pm and am during the night of the 19th in to the 26Y April: Mr Fry was peripherally cold and it was difficult to obtain an arterial reading: A SHO was consulted who advised that another attempt to obtain an arterial reading be made between 5 am and that IVfluids were to continue_ Mr Fry again displayed no physical signs of a DVT or PE: Shortly before 6 am on the 20th April the CCOT worker returned she was told that at 5.10 there had been drop in Mr Fry's oxygen saturations and mask and then nasal oxygen had been administered and his oxygen levels had risen he continued to have a news of 11_ He was last observed at 5.45. At 6 am Mr Fry was found unresponsive and despite attempts could not be resuscitated. 17th Fry Fry drug entry again

The medical cause of death after Post Mortem Examination was recorded as Pulmonary Embolism 1b) Deep Venous Thrombosis II Fracture of the Lumbar Spine

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