Page 11 - Adult C Overview Report - FINAL

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that there was no change to the vulnerability of Adult C despite many support agencies

involvement over several years.

5.25. Adult Social Care immediately contacted the housing charity and the police to share concerns.
Police did not take any action on this information, the housing charity stated that they would
discuss with DA2. DA2 have no record of receiving contact from the housing charity.

5.26. Adult Social Care safeguarding team allocated the case for assessment to the local access
team with an appointment made for two weeks’ time to meet up with Adult C. DA2 contacted

Adult C the day before the appointment to remind her. Adult C did not arrive for this
appointment. The following week, on ascertaining that Adult C had forgotten about the
appointment but was still keen to be seen, an appointment was arranged the following week.
Adult C died before this rearranged appointment.

5.27. Four days before the death of Adult C, she contacted the GP practice in the morning,
concerned about pain in her chest which was worse on breathing. Adult C was advised to call
999 but stated she wanted to see her GP; she was advised to call 999 if symptoms got worse.
Seven hours later Adult C called the GP practice again stating that she was worse, at this point
she agreed to attend the surgery. The GP recognised symptoms of possible sepsis and
arranged an ambulance to convey her to hospital after being persuaded not to leave the

practice and to be picked up there rather than going home.

5.28. Adult C was promptly conveyed to the Acute Hospital. Once in Accident and Emergency, Adult
C was diagnosed with possible chest infection, low blood potassium and pulmonary embolism
(blood clot in a blood vessel of the lung). Adult C reported that she had not been taking her
prescribed oral potassium supplements as she had not been able to keep food and water
down, although she appeared well hydrated at that time. Adult C was administered with an
anticoagulant (treatment for blood clots), prescribed oral potassium, advised to ensure

adequate oral nutrition and hydration. Adult C was requested to attend Ambulatory Care at
the hospital the next morning to have a computed tomography pulmonary angiography
(CTPA – diagnostic scan for a pulmonary embolism) and discharged with the advice that if
vomiting persisted to return to the department for intravenous potassium replacement.

5.29. The next day Adult C attended the Ambulatory Care Unit and was diagnosed with a
community acquired pneumonia by a Nurse Practitioner. Adult C was prescribed a course of a
combination of two oral antibiotics and a follow up review planned for in six weeks. The CTPA
was not requested at this review as the x-ray showed infection and not embolism.

5.30. In the early hours of the next morning, Adult C’s ex father in Law called 999 as Adult C

continued to be unwell. A crew was dispatched but Adult C refused to go to hospital, stating
that she was merely seeking advice. She signed the electronic record declining treatment and

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