Timothy Cowen

On the 9th of May 2013 commenced an investigation into the death of Timothy Peter Cowen (DOB 6.9.61, DOD 2.5.13). The investigation concluded at the end of the inquest on the 30th of September 2014 and recorded a narrative conclusion in the following terms On the 23rd April 2013 Timothy Peter Cowen underwent an operation at the Maelor Hospital, Wrexham having previously undergone a substantial pre-operative assessment which took into account his severe learning disabilities and significant mobility limitations_ The operation itself was uneventful and post operatively he was returned to the ward for ongoing care_ He received nutrition by way of a peg feed and his feeding regime had been established over a long period of time such that he would receive nutrition in two daily sessions whilst upright Post operatively this regime was changed in accordance with recognised dietary practices and he then received a single reduced dose of feed over a longer period whilst being propped up in bed: It is probable that during this period as a result of his existing medical conditions he aspirated resulting in infection. He was assessed as being fit for discharge on the morning of the 25th April 2013, although his actual discharge did not take place until that same evening at which point his carers who knew him best were concerned that his condition may have deteriorated rendering him unfit for discharge. Such concerns were not brought to the attention of nursing or medical staff at that time: Over the course of the next three days his condition continued to deteriorate resulting in his re-admission to the Maelor Hospital on the 28th April 2014_ Despite surgical investigation and ongoing support he passed away on the 2nd May 2013 at 21.25 hours on ITU. as a result of Bilateral Extensive Pneumonia with features of Aspiration.

The Circumstances of the death are outlined the above narrative conclusion:

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