Ernest Gray: Prevention of future deaths report

1.  Chief Executive East Kent Hospitals University NHS Foundation
Trust

I am Patricia Harding, senior coroner for the coroner area of Kent and Medway

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

On 4^th December 2023 I commenced an investigation into the death of Ernest Roy Gray 95. The investigation concluded at the end of the inquest on 4^th November 2025. The conclusion of the inquest was that Ernest Gray died of natural causes with how when and where he came by his death being recorded that Ernest Gray was taken to hospital after he became unwell on 19th November 2023 and was diagnosed with ongoing delirium and intravascular dryness following a recent myocardial infarction on a background of heart failure, chronic kidney failure and hypertension. He died on 24th November 2023 at William Harvey hospital after developing pneumonia with a conclusion of Natural Causes

Ernest Gray lived with his partner of 30 years, it was a loving relationship. On 6^th November 2023 Mr. Gray had been admitted to QEQM hospital after he suƯered a myocardial infarction. On 8th November 2023 he presented as agitated & confused and was diagnosed with hyperactive delirium and heart failure Thereafter he was variously described as calm or agitated and aggressive at times, getting out of bed and wandering. He was irrational and demanding to be taken home. On 10^th  November 2023 a DOLs was put
in place and remained for duration of stay. On 11^th November 2023 he was aggressive, throwing things from a table and trying to hit staƯ. He refused all medications but was calm in the afternoon. His behaviour could be characterised as experiencing episodes of agitation followed by periods of calm when he became apologetic. Over the course of next few days he was medically optimised for discharge as his hyperactive delirium was resolving and there were no further  incidents of aggression although he remained confused. He was discharged from hospital on 15^th November 2023 to his family home.

There was little evidence about his condition after discharge, those that saw or spoke to him described his behaviour as unusual.
On 18^th November 2023 Ernest Gray flagged down someone in the street asking for help. His partner was discovered deceased in the kitchen. It was
later established that she had been subjected to a sustained attack 
[REDACTED]
 
Ernest Gray was arrested. After examination by a nurse he was declared to be fit to be detained and he was later interviewed during which he made some  admissions,  some  statements  which  were  contradictory  within themselves  and  with  other  statements  and  some that  were  confused. Within three hours of the interview Ernest Gray became unwell and was taken to hospital where he was diagnosed with hyperactive delirium and heart failure. He remained under constant supervision of the police whilst being cared for in hospital and within 12 hours of admission attacked one of the police officers whilst being attended by a nurse; [REDACTED] Gray died 4 days later.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows.
(1) Mr. Gray’s next of kin was his daughter but he lived with his 86 year old partner.  His  daughter  was consulted  in the  discharge process  but  the hospital did not attempt to contact his partner who was his carer.
(2) Although a number of persons from diƯerent disciplines were involved in  planning  Mr.  Gray’s  discharge,  there  was  no  evidence  of  a  holistic approach being taken of the discharge or in communication of the patient’s ongoing needs following discharge
(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated  and  violent  in  hospital,  nor  was  she  told  that  although  the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr.  Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report, namely by 5^th January 2026. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Family of Ernest Gray, family of his partner, Kent Police

I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.

I may also send a copy of your response to any other person who I believe may find it useful or of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.

You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.