Coroner calls for clearer hospital discharge notes after death

THE coroner is asking Grimsby's hospital to write clearer directions on care when people are discharged – after a man died following confusion.

An inquest into the death of George Jorgensen, 71, heard how he died at Temple Croft Care Home, Scartho Road, Grimsby, on October 25 last year – the same day he was released from the Diana, Princess of Wales Hospital.

Coroner Paul Kelley concluded that his death was the result of an accident, but noted that Temple Croft staff were forced to "seek clarification" on aspects of his care after release.

Mr Kelley said: "The written instruction on his discharge was not as clear and comprehensive as it could have been.

"I will write to the hospital recommending that additional care is taken to make sure it is more concise, clear and manageable than seems to have been the case in this situation."

The inquest heard how Mr Jorgensen died from aspiration – food trapped in the windpipe – according to consultant pathologist Dr William Peters' post mortem examination report.

A statement from Dr Kamath, who had treated Mr Jorgensen at hospital, said his patient was unable to swallow and was fed through a tube – but was in good health when he was discharged.

Jennifer Bell, from the speech and language therapy department at the hospital, said discharge notes advised that Mr Jorgensen should also be given five teaspoons of food with a custard consistency, four to five times a day.

Hospital nurse Melanie Hotson said that Temple Croft had two training sessions to learn how to use a tube into his stomach.

However, Temple Croft care manager Ann Martin felt the discharge notes were not clear.

She told the inquest that food product FortiFeed was mentioned in the notes, but staff didn't know if this was to be used for feeding or as well as food.

Mrs Martin said she tried to ring the ward but no one who had treated Mr Jorgensen was available when he was given FortiFeed, about 90 minutes after dinner.

He was found not breathing in his chair shortly after and Mr Kelley said it was clear that the contents in his windpipe had "never made it to his stomach".

Kathryn Helley, deputy director of clinical and quality assurance, said: "We await the correspondence from the coroner and will, of course, comply with any requests made."

Mr Jorgensen was the uncle of Paul Hodge, who died with his friend David Williams in the Great Coates level crossing tragedy in April, when his car was hit by a train.

Paul's mother – Mr Jorgensen's sister – Doris Collier, 70, of Peaksfield Avenue, was at the inquest.

Afterwards, she said: "George was a lovely man and a quiet soul – I don't understand what happened as he seemed fine in the hospital."