Page 12 - Adult C Overview Report - FINAL

This document was classified as: OFFICIAL

was advised to see her GP later that day if she continued to feel unwell. There was no

evidence that Adult C had been drinking or that there were issues related to a requirement to
assess mental capacity regarding her decision to refuse treatment.

5.31. Two days later, an ambulance was again called. Adult C was coughing, struggling with her
breathing and was agitated. The call advisor calmed Adult C down and ascertained, using
pathways triage, that an ambulance was required within a two-hour timeslot. Three quarters
of an hour later, a further phone call was made stating that Adult C was grey and then started
fitting. An ambulance was immediately dispatched and arrived seven minutes later. Adult C

could not be resuscitated, and death was pronounced 30 minutes later.

5.32. Adult 1 and Adult C’s ex father in law were originally arrested on suspicion of murder;
however, they were later cleared after a forensic post-mortem declared death from natural
causes.

6. GOOD PRACTICE

6.1. It is important to note that many practitioners offer a good level of service to their
clients/patients and follow policies and procedures that are provided to guide practice. This
review has identified a plethora of good practice that is discussed throughout this report.

6.2. Many agencies have responded immediately to the learning that they have identified and
commenced changes as well as using this case to further system changes that were already in
progress.

7. ANALYSIS

7.1. The analysis section takes a strengths-based approach identifying what went well and
building a picture of areas where learning has occurred. Adult C had an extensive history of
being involved with services over the previous seven years. Much of that time period covers

systems that have changed as well as changed policy and legislation. The background
provided to this review offers a contextual perspective but will also be drawn on where it
impacts on current learning and systems. The first three sections identify learning regarding
domestic abuse, alcohol dependency and physical health with the final section identifying the
complexities of those three areas impacting on each other.

7.2. It is of note that Adult C died of natural causes. Those were identified as pneumonia with a
secondary cause of liver problems related to alcohol consumption. Adult C did not die as a
direct result of domestic abuse. She did, however, die of complications from her alcohol
consumption. It should be noted, that pneumonia is a disease that can also cause death in

healthy adults.

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