Benedict Peters

I am Chris Morris, Area Coroner for Manchester South.

On 27th January 2023, Lauren Costello, Assistant Coroner opened an inquest into the death of Benedict Peters who was found dead on 12th November 2022 whilst staying at his parents’ home, aged 25 years. The investigation concluded with an inquest which I heard on 4th May 2023. A post mortem examination confirmed that Mr Peters died as a consequence of: 1a) Haemopericardium; b. Acute aortic dissection. The conclusion of the inquest was a narrative conclusion to the effect that Mr Peters died as a consequence of complications arising from an underlying heart defect which had not been diagnosed during his life.

Mr Peters was found dead at his parents’ home on 12th November 2022 having been staying there following his discharge from the Manchester Royal Infirmary Ambulatory Care Unit the previous day. Mr Peters had attended hospital in the early hours of 11th November 2022 having become acutely unwell with chest pain, shortness of breath, a sore throat and an aching arm. In the Emergency Department, an ECG was undertaken which was reported as showing Normal Sinus Rhythm and his recorded observations were essentially normal. Whilst awaiting review, Mr Peters experienced a severe episode of vomiting. Blood tests were taken and Mr Peters’ Prothrombin time was noted to be abnormal. Troponin and D-Dimer levels were within normal limits. Mr Peters was reviewed on the Ambulatory Care Unit by a Physician Associate. A Chest X-Ray was performed which was reported as being normal and following discussion with the duty Consultant, Mr Peters was discharged with a diagnosis of panic attack / gastric inflammation and a prescription of Propranolol and Omeprazole.

CORONERS CONCERN During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined / reviewed in person by a doctor. It is a further matter of concern that (according to the evidence of [REDACTED] , Consultant Physician) no policy or protocol exists within the Trust as to when patients may or may not be discharged from the Ambulatory Care Unit without a medical review taking place.

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