Source · Prevention of Future Deaths

Wilfred Aspinwall

Ref: 2014-0283 Date: 25 Jun 2014 Coroner: Andre Rebello Area: Liverpool Responses identified: 0 / 1 View PDF

Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.

Date 25 Jun 2014
56-day deadline 20 Aug 2014
Responses identified 0 of 1
State Custody related deaths

Coroner's concerns

AI summary
Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
View full coroner's concerns
At the inquest hearing it was clear that the PPO report and Clinical Review had not been sent to nor shared with the Healthcare provider at HMP Liverpool. It might be considered good practice for future reports, in all prison fatalities should to be sent to either the head of healthcare and/or the commissioning NHS Trust to ensure that recommendations have an optimal effect.

Report sections

Investigation and inquest
On the 30th April 2013 I commenced an investigation into the death of Wilfred Roy ASPINWALL by opening an inquest under the Coroners Act 1988 , Aged 82. The investigation concluded at the end of the inquest on 24th June 2014. The conclusion of the inquest was

Ia Congestive Heart Failure Ib Hypertensive Heart Disease II Recurrent and Metastatic Lung Carcinoma

Wilfred Roy Aspinwall died of Natural Causes
Circumstances of the death
Wilfred Aspinwall was a prisoner at HMP Liverpool. He was a frail gentleman with several co-morbidities. Whilst in Prison was residing on the health care ward. He had sustained previous falls at prison and sustained a further fall on 7th/8th March 2013, fracturing his hip and was then transferred to University Hospital Aintree. Whilst in UHA, he has sustained further falls on Ward 35. He suffered a gradual deterioration of health and on Sunday 21st April 2013, Wilfred’s breathing became laboured at 0910hours and he sadly died. Medical history included Lung cancer, with part of lung being removed in 1995, renal failure and worsening dementia. There was considerable confusion concerning the cause of death after both a consultant histopathologist and a consultant neuropathologist attributed fatal events to cerebral pathology caused by falls. The Court instructed a consultant neurosurgeon who met with the pathologists reviewed the clinical presentation including scans, where after all three doctors agreed that the death was due to natural causes.

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Report details

Reference
2014-0283
Date of report
25 June 2014
Coroner
Andre Rebello
Coroner area
Liverpool

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Aug 2014.

Sent to

Prison and Probation Ombudsman

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