Coroner's Conclusions

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 Police found a number of syringes believed to be steroids and two insulin pens, one of which was out of date.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.