Terence Briney

Stockport Integrated Care Partnership              

4th Floor, Stopford House 
Piccadilly 
Stockport 
SK1 3XE 

Date:  2nd April 2024  

Private & Confidential 
Ms Alison Mutch 
H M Senior Coroner  
1 Mount Tabor Street 
Stockport 
SK1 3XE  

Dear Ms Mutch  

Inquest into the death of Mr Terence Briney  -  Date of Death 17 March 2023  

I refer to the Regulation 28 Prevention of Future Deaths Report issued following the inquest 
into the death of the above named.  I am sorry to learn of the circumstances of Mr Briney’s 
death and offer my sincere condolences to his family.  

You seek assurance in response to the following cause for concern:- 

The inquest heard evidence that symptoms raised by Mr Briney and his family 
were attributed to old age rather than a possible neurological disease.  The 
evidence before the inquest was that there were situations where clinicians 
would attribute deterioration to the ageing process rather than consider the 
whole picture and investigate if there was a treatable condition.  This presented 
a risk that treatable conditions in the elderly could be missed. 

In  order  to  address  this  concern  we  have  liaised  with  Mr  Briney’s  GP  and  Stockport  NHS 
Foundation Trust (Stepping Hill Hospital). 

Mr Briney attended A&E at Stepping Hill Hospital on 19th May 2022 following a fall down a 
full flight of stairs backwards. He underwent a CT scan of his cervical spine which showed no 
evidence of acute cervical injury. He also had a CT head which showed no haemorrhages, no 
space-occupying lesions, and no obstructive hydrocephalic changes. There were generalised 
involutional changes noted which were put down to chronic small vessel disease. A soft tissue 
swelling was noted and a right occipital skin discontinuity which was commented on as being 
a likely post-traumatic laceration. The CT head summary showed ‘no evidence of intercranial 
haemorrhage or recent territorial infarct’ 

He initially had his wound sutured in A&E and was due to be discharged but experienced a 
vasovagal episode on return from the toilet following this, and therefore went on to have an 
ECG,  blood  tests  and  a  chest  x-ray  and  was  referred  to  the  medical  team.  He  was  then 

 
 
 
                    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
  
  
 admitted under the medical team from 19th May 2022 until 25th May 2022 and the reason for 
admission  on  the  discharge  letter  is  ‘fall  with  head  injury’.  His  Amlodipine  and  Diltiazem 
medications were stopped due to low blood pressure during this admission. 

Mr Briney’s family believe that Mr Briney health deteriorated following this significant fall in 
May 2022. 

On review of notes, there was no report or documentation of lethargy or tremors when the 
gentleman presented at the practice or when his family contacted the practice.  It was not 
until Dr Hudson visited the Mr Briney on 15th March 2023 where she noted forearm 
fasciculations which the family reported had been present for 12 months.  This however 
had not been noted in any previous interactions between Mr Briney and the practice. 

Mr Briney’s weight loss was first noted in a consultation on the 27th July, when he reported 
that he had been eating less.  It was not discussed again until a consultation on 3rd of 
February 2023. 

 visited Mr Briney at home on the 15th March at the gentleman’s wife’s request.  

His  family  were  very  concerned  about  ongoing  weight  loss  and  general  deterioration. 

 discussed the results of the CT scan with the family which did not show any cancer 
and that he had a follow-up arranged with 
 at Stepping Hill in April. They reported 
that  the  previous  year  he  had  walked  three  to  four  miles  but  now  had  very  poor  mobility 
within  the  home.  He  had  a  17kg  weight  loss.  He  had  difficulty  swallowing  solids.  He  had 
slurred speech. He felt tired all the time and very weak. He had urinary incontinence.  

On examination 
 found him to be very frail with slurred speech, his blood pressure 
was  slightly  low  at  101/69,  his  pulse  was  79  bpm  regular  which  is  normal,  and  his 
  observed  fasciculations  (twitching 
temperature  was  normal  at  36.1  degrees. 
muscles) in the muscles of his left forearm as he was at rest.  

 decided to admit him acutely under the medical team and wondered whether he 
 referred him 
may have a neurological condition such as motor neurone disease. 
to the same-day emergency care unit at Stepping Hill and advised he should go in via A&E 
and his wife agreed to arrange for an ambulance to take him there.  

Mr Briney was admitted to Stockport NHS Foundation Trust (Stepping Hill Hospital) on 15 
March 2023 following referral by his GP due to a rapid deterioration for the last month; a 
past medical history was noted as follows:- 

•  Hypertension 
•  High lipid level 
•  Previous history of angina 
•  Moderate AS 
•  Recent diagnosis of dysphagia and weight loss of around 14 kg 
•  Barium  swallow  23.2.23:  moderate,  silent  penetration  of  the  airway  is  seen  during 

swallowing.  Marked dysmotility of the oesophagus is noted 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 
 
   had  been  cutting  up  her  husband’s  food)  following  episodes  of  choking.   

Discussion with family highlighted a 12-month history of weight loss with significant muscle 
waste over the last  6 months.   They also raised concern  in regard to Mr Briney’s swallow 
(
Regarding the deterioration in mobility if was noted that Mr Briney had attended an evening 
at the theatre in January 2023 but was now housebound.  The family also reported slurred 
speech and difficulty in understanding what Mr Briney was saying along with fluctuating levels 
of confusion.   

On arrival to the Emergency Department, Mr Briney’s observations were stable.  His NEWS 
score was 0 in the ambulance but on arrival scored 1 due to confusion.   On examination 
there was nothing significant apart from the  fact that he was dry and looked dehydrated.  
His neurology examination appeared normal but there was significant muscle waste.  Bloods 
did not raise any concerns for infection.   

At  this  stage  there  was  no  clear  indication  of  what  had  caused  the  deterioration  but  the 
following considerations were noted:- 

-  Neurological pathway or rapid onset of dementia 
-  Significant frailty 
-  Confusion query cause, possibly in the context of rapid onset dementia 

At  this  point  further  investigations  were  ordered  to  be  performed  including  ECG,  IV  fluid, 
referral to gastroenterology due to marked oesophageal disability.  A SALT review was also 
requested to evaluate Mr Briney’s swallow and a neurology review for clarification of cause 
of the deterioration.   

The  following  morning  it  was  noted  on  consultant  review  that  Mr  Briney’s  GCS  score  had 
deteriorated and was now 12/15.  The working diagnostic was probable vascular dementia.  
Further  investigations  were  ordered  including  a  CT  head  and  PR  examination  (which  was 
normal).  In view of the pattern of cognitive decline syphilis serology was also requested. 

An  urgent  CT  scan  was  performed  and  reviewed  that  day  revealing  isodense  extra  -axial 
collections  overlying  both  cerebral  convexities  (right  more  than  left).    The  findings  were 
suggestive of chronic subdural haematoma or subdural hydroma.  There was no associated 
mass-effect.  It was advised for neurosurgical team referral. 

Advice from the neurological team following review of the CT scan was as follows:- 

(1) Bilateral isodence subdural collection -  Minimal midline shift 
(2) PS3  deterioration  (query  whether  this  was  new).    This  referred  to  baseline  of 
independence and was documented: Confined to bed/chair more than 50% of waking 
hours 

Neurological impression was that it was unlikely that presenting symptoms were unrelated 
to CT head findings.  

The following plan was agreed:- 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 
 
 
 (1) No need for neurological intervention 
(2) Admit locally 
(3) Neuro observations 
(4) Investigate other causes for deterioration in mobility - if slurred speech is new to rule 

out stroke 

(5) If Mr Binney deteriorates to re-scan and re-discuss 
(6) Clear C Spine  

Neurological consultant input was agreement that the chronic subdural collection was unlikely 
to be related to presenting symptoms.  No neurological intervention indicated but a plan to 
re-scan within 2-4 weeks in the event that Mr Briney did not return to his baseline.   

Later that night (early hours of 17 March 2023 Mr Briney was reviewed by the on-call doctor 
due to a sudden deterioration of his saturation.  Sats had dropped to 80% with Mr Brinney 
already on 15L O2 which had not been required previously.  Suction was attempted but there 
was no improvement.   

Arterial blood gas revealed further deterioration indicating mixed metabolic and respiratory 
acidosis with very low pH (7.130) and high CO2 (13.95) and high lactate (3.0). 

This was considered to be in keeping with an acute respiratory event, likely from aspiration 
of own saliva which had been the main concern at the point of admission.   

Shortly after this Mr Briney was reviewed further by the on-call Registrar who noted a drop 
in GCS and hypoxia.   

At this stage the Registrar was concerned that this was potentially an NSTEMI, noting the 
ECG to have revealed a ST depression on the arterial lead.  The plan was for treatment for 
Acute Coronary Syndrome (ACS); there also remained concern re the findings from the CT 
scan.  Mr Briney was prescribed Fondaparinux and aspirin as treatment for ACS. 

At  08:30  on  17  March  2023  Mr  Briney  was  reviewed  again  and  further  deterioration  was 
noted. Family was contacted and made aware of the significant deterioration and that it was 
likely that Mr Briney was entering the dying stage.   

, Consultant, reviewed Mr Briney at 09:23 and whilst he was writing his notes, Mr 

Briney was noted to have sadly passed away.   

In light of the Prevention of Future Deaths Report, the GP Partners reviewed Mr Briney’s case 
and  discussed  if  and  what  could  have  been  done  differently.  They  analysed  all  of  the 
interactions between Mr Briney and the practice from the point of his discharge from Stepping 
Hill Hospital on 25 May 2022 (this admission had been due to a fall down a flight of stairs). 

They highlighted the consultation on the 3rd February 2023.  

Mr Briney attended to see 
his fall in May 2022 and his subsequent decline as outlined below. 

 with his wife and daughter. There were concerns following 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 
 
 
 
 ▪  Weakness in hands 
▪  Ongoing dizzy spells and falls 
▪  Reduced appetite 
▪  Weight loss 
▪  Choking on food 
▪  Nausea when eating 
▪  Confusion 
▪  Reduced mobility 

At this point his wife was having to fully care for him. 

His weight was documented at 57kg, and it was arranged for him to have further bloods and 
referrals to the dietician/falls team/frailty team. His daughter was advised to contact Adult 
Social Services for further support. 

 discussed with a colleague (not named in the notes) regarding his choking, weight 

loss and nausea and the possibility of a gastroscopy was discussed. 

During this consultation 

 and agreed to make referrals to:  

-  Dietician 
-  Falls Team  
-  Frailty Team  
-  Upper GI Suspected Cancer Pathway under the two week wait rule. 
-  Daughter was contacting Adult Social Care and Social Services for support in arranging 

an attendance allowance.  

- 

These referrals were processed and sent on the 6th February.  

The consensus amongst the GP Partners was that the two week wait referral along with the 
other referrals to local services were appropriate. These were appropriate referrals given Mr 
Briney’s symptoms, which were suggestive of a possible upper GI cancer.  

Given  the  comments  in  the  Regulation  28    Report:  ‘The inquest heard evidence that 
symptoms raised by Mr Briney and his family were attributed to old age rather than a possible 
neurological disease’, the GPs discussed whether they would have considered a referral to 
neurology at this stage.  However, on reflection Mr Briney’s symptoms were in keeping with 
a possible upper GI cancer and it was deemed clinically appropriate to exclude cancer first 
before investigating other referral options.  

Whilst it was discussed that perhaps a neurological referral could have been made following 
the  consultation  on  the  3rd  of  February,  until  this  point  and  in  the  absence  of  any  focal 
neurological  symptoms  or  specific  neurological  symptoms  such  as  fasciculation  being 
previously reported to his GP it was always more likely that his symptoms were due to a more 
prevalent/common pathology, e.g. upper GI cancer as a cause of swallowing problems with 
weight loss, choking and nausea in an older adult,  postural hypotension leading to falls and 
progressive frailty following falls leading to further functional deterioration in an older patient. 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 
  
 If a neurological referral had been done on 3rd February 2023, it is difficult to be certain if he 
would have received an appointment by 15th March 2023 given current waiting times of many 
months, even for urgent referrals.  

If he did see a neurologist and had received a neurological diagnosis, Mr Briney and his family 
could have received information and support. However, it is uncertain whether a referral and 
diagnosis would have changed the outcome in terms of his prognosis.  

The  GPs  also  reflected  that  here  at  Cheadle  Hulme  medical  group  we  operate  a 
principal/personal  list  and  as  a  practice  we  strive  for  continuity  of  care.  It  is  not  always 
possible and on reflection perhaps if Mr Briney had seen the same clinician on every occasion 
post his fall in the May 2022 before Dr Hudson visited him at home, it is possible his decline 
may have been more noticeable.  

Since July 2023 we have moved to a total triage model and all medical requests are triaged 
by  a  GP  who  will determine  the  next  course  of  action  thus  ensuring  continuity  care  more 
successfully.  

During the reflection process, it was also discussed that although Mr Briney and his family 
did respond to text messages from the practice, that there could be more consideration to 
the age of patients who we engage with via text message. Whilst it is common practice for 
the  GPs  to  discuss  with  the  patients  that  they  are  going  to  send  them  a  text,  we  should 
always  ensure  that  they  are  able  and happy  to  receive  and  respond  using  this  method  of 
communication. 

Having  reflected  and  discussed  Mr  Briney’s  presentation,  all  GPs  are  now  more  likely  to 
consider  neurological  causes  for  weight  loss  and  swallowing  difficulties  in  older  people, 
alongside the need to rule out cancer, which would always, realistically need to be done first. 
This consideration to be documented in the notes to aid other clinicians who may see the 
patient subsequently. 

By coming together to review and discuss the circumstances surrounding Mr Briney’s case, 
this has increased the likelihood of GPs considering the possibility of neurological conditions 
in older people presenting with similar symptoms.  It has also facilitated detailed discussion 
and  hence  shared  learning.    However,    the  partners  felt  that  they  would  not  have  acted 
differently in this case given the symptoms and information available at the time.  

From the review of this case, I am satisfied that both the GP Practice and the hospital team 
did  make  effort  to  identify  treatable  causes  for  this  gentleman’s  presentation  and  that 
appropriate investigations were ordered, and expert advice sought with a view to appropriate 
treatment.  It is acknowledged that the neurological referral could have been made following 
the GP consultation on 3 February 2023 although it is unclear whether this would have led 
to an appointment for this gentleman prior to his admission to hospital the following month.   

The overall review of this case highlights that communication with the family was not always 
as timely and I am disappointed to see that family were not contacted overnight on the night 
of  16  –  17  March  2023  when  the  significant  deterioration  in  this  gentleman’s  condition 
occurred as this would have enabled the family to have more time with Mr Briney in the final 

                                                                                                                                               
 
 
 
 
 
 
 
 
 
 hours of his life.  I appreciate that we cannot make this right but I would ask that my sincere 
apologies  are  conveyed  to  Mr  Briney’s  family  for  the  delay  in  contacting  them  at  such  an 
important time.   

I hope the above is helpful to you but if you do require any further information please contact 

Yours sincerely 

Deputy  Chief  Nurse  (Quality  and 
Safety) 
p.p. on behalf of  

Interim Deputy Chief Executive  
And Chief Nursing Officer 
NHS GM Integrated Care