PCO000008-0001

Coroners Officer:

INQUEST INTO THE

Leslie C PI

OF

es

Case Number: 1002/08

Opened 14th May 2008

Inquest Date: 18/~3/.2~/.

PC0000008-0002

CORONER’S OFFICERS’ INQUEST CHECKLIST

Case Name: Leslie Charles PITTOCK

Case Ref: 1002/08

DOCUMENTS REQUESTED:

REQUESTED FROM

N/A

N/A

DOCUMENT

Post Mortem

Toxicology

Other Medical

Police Report

Other Reports & Statements

Det Chief Supt Williams

DATE RECEIVED

FUNERAL DIRECTORS

FAMILY DETAILS

Mrs L Wiles (._D..aug.h_.ter)

PC0000008-0003

Code A

PC0000008-0004

Name and Surname of deceased

Leslie Charles PITTOCK

To be completed by Registrar

District & SD No.

Register No.

Entry No.

PART V ACCIDENT OR MISADVENTURE (including deaths from neglect or from anaesthetics)

1. Place where accident occurred

O. Home 5. Street or highway 1. Farm 6. Public building 2. Mine or quarry 7. Resident institution 3. Industrial place or premises 8. Other specified place

4, Place of recreation or sport 9. Place not known

To be completed for all persons aged 16 and over

When injury was received deceased was

1. On way to, or from work

2. At work 3. Elsewhere

3. Details of how accident happened :

If motor vehicle incident, deceased was

0. Driver of motor vehicle other than motor cycle 1. Passenger in motor vehicle other than

motor cycle 2. Motor cyclist 3. Passenger on motor cycle

4. Occupant of tram car

5. Rider of animal; occupant of animal-drawn vehicle

6. Pedal cyclist 7. Pedestrian 8. Other specified person

9. Not known

Interval between injury and death

1. Less than one year 2. One year or more

Form 99(REV)B

01002 - 2008

PCO000008-0005

Narrative Verdict

Leslie Charles PITTOCK

The deceased was an inpatient at Gosport War Memorial Hospital and was receiving Opoid Medication at the time of death. The administration of medication did not contribute more than minimally or negligibly to the death of the deceased.

PC0000008-0006

Code A

PC0000008-0007

Code A

PC0000008-0008

Name and Surname of deceased

Leslie Charles PITTOCK

To be completed by Registrar

District & SD No.

Register No.

Entry No.

PART V ACCIDENT OR MISADVENTURE (including deaths from neglect or from anaesthetics)

1. Place where accident occurred

0. Home 5. Street or highway 1. Farm 6. Public building 2. Mine or quarry 7. Resident institution 3. Industrial place or premises 8. Other specified place

4. Place of recreation or sport 9. Place not known

To be completed for all persons aged 16 and over

When injury was received deceased was

1. On way to, or from work

2. At work

3. Elsewhere

3. Details of how accident happened :

4. If motor vehicle incident, deceased was

o

0. Driver of motor vehicle other than motor cycle

1o Passenger in motor vehicle other than motor cycle

2. Motor cyclist 3. Passenger on motor cycle

4. Occupant of tram car

5. Rider of animal; occupant of animal-drawn vehicle

6. Pedal cyclist 7. Pedestrian 8. Other specified person

9. Not known

Interval between injury and death

1. Less than one year 2. One year or more

Form 99(REV)B

01002 - 2008

PCO000008-0009

Narrative Verdict

Leslie Charles PITTOCK

The deceased was an inpatient at Gosport War Memorial Hospital and was receiving Opoid Medication at the time of death. The administration of medication did not contribute more than minimally or negligibly to the death of the deceased.

PCO000008-0010

3.12

3.13

3.14

Drug Chart Analysis:

On 5t" January at transfer 16M), Mr Pittock iswritten up for the standard drugs that he was on in the.mental health ward including his Sertraline and Lithium (for his depression) D!azepam (for his agitation) Thyroxine for his hypothyroidism. The drug (;hart also had Diamorphine 40 - 80 mgs subcut in 24 hours Hyoscine 200 - 400 micrograms subcut in 24 hours and-Midazol~m 20 - 40 mgs subcut in 24 hours. Midazolam 80 mg subcut in 24 hours written up but not dated and never prescribed. (18M)

On 10th January, Oramorph 10 mgs per 5 mls is written up for 2.5 mls four hourly and prescribed on the evening of 10th and the morning of the 1 lth. On the 1 lth Oramorph 10 mgs per 5 mls is written up to be given 2.5 mls 4 hourly 4 times a day with 5 mls to be given last thing at night. This is then given .regularly between 11t" and up to early morning on 15t" January. This is a total daily dose of 30 mgs of Morphine (19M). The Lithium and Sertraline are crossed off after the 10t" January.

Diamorphine 80 - 120 mgs subcut in 24 hours is written up on 1 lt" January "as required" as is Hyoscine 200 - 400 micrograms in 24 hours, Midazolam 40 - 60:mgs in 24 hours. 80 mgs of Diamorphine together with 60 rags of Midazolam are then started by syringe driver on the morning of the 15t" January and re-started on both the mornings of the 16t" and 17t" January. (18M). On 16t" January Haloperidol 5 mgs- 10 mgs subcutaneous for 24 hours is written up, prescribed over 24 hours on both 16{h and 17th, 1 am not clear if this was mixed in the other syringe driver or was the "second pump" refe.r.red to in the nursing cardex. (20M and 27M)

PCO000008-0011

Diamorphine 120 mgs subcut in 24 hours is then prescribed on 18th January, together with Hy~oscine 600 mgs subcut in 24 hours. The drug charts (20M) show this starting on the morning of 17th January and at 08.30 hours. If this correct there may have been up to three syringe drivers running, one with Diamorphine 80 mgs, one with Diamorphine 120 mgs in and one with the Haloperidol. The reason for this confusion needs clarification, but is possibly a nursing error with the drug. chart.

The subsequent drug charts all appear to be missing for the final 6 days, however the nursing notes (27M, 28M and 29) suggest that there was a fairly constant prescription of 120 mgs of Diamorphine 24 hours, Midazolam 80 mgs 24 hours, Hyoscine 1200 mgs, Haloperidoi 20 mgs and Nozinan 50 mgs. On the 20th there was no Haloperidol and the Nozinan was increased 100 mgs a day. This is still the prescription on 23rd January (27M).

Drug Oramorphine

Diamorphine

Midazolam

Diamorphine

Midazolam

Midazolam

Oramorphine

Oramorphine

Diamorphine

Date prescribed 10/01

11/01

11/01

? 16/01

11/01

11/01

18/01

Prescribed as ’ Prescriber 10mgsin5mls ~Barton 2.5 mls, 4hrly oral Regular

40 mgs SIC in Barton 24 hours Regular

NEW DRUG CHART 20 - 40 mgs SIC Barton in 24 hours Regular 80 - 120 mgs Barton SIC in 24 hours PRN 40 - 60 mgs Barton SIC in 24 hours PRN 80 mgs SIC in Barton 24 hours PRN 10 mgs in 5 mls Barton Oral 2.5 mls 4 hourly Regular 10 mgs in 5 mls Barton Oral 5 mls nocte

120 mgs Barton SIC in 24 hours

Given 10/01 2200 11/01 0800 (never crossed out)

Never given or crossed off

Never given or crossed off

15/01 ? 80mgs 16/01 0815 80mgs 17/01 ? 80mgs 15/01 ? 60mgs 16/01 ? 60mgs 17/01 ? 60 mgs Never given "

Regular doses 4 times a day until 0600 on 15/01 No further doses Not crossed off 11/01 - 15/01 2200 No fu rt h e r_ ~;!.O.s_e_.s__ Not crossed off "17101" 0830 120 rags (probably 18101 )

PC0000008-0012

The National Programme on Substance Abuse Deaths (np-SAD)

I NOTIFICATION OF DRUG RELATED DEATHS I Section I Demo~raohic Information

Deceased forename(s):

Family Name:

Date of birth :

Usual Address :

Leslie Charles Gender: [] Male [] Female

PITTOCK Other names known by: None

i ....... -I~i-~~ ....... i Place of birth: Hemel Hempstead, Hertfordshire

Postcode :

~i ~whicity : (tick one only) ite [] Pakistani

[] Chinese [] Bangladeshi

[] Not Known [] Indian

[] Black African

[] Black Carribean

[] Black other, specify:

Occupational Status : (tick one only)

[] Employed (Manual) [] Unemployed

[] Employed (Non-Manual) [] ChildcareiHouseperson

[] Self employed [] Invalidity/Sickness

Living Arrangements : (tick one only)

[]Alone [] Self& children

[] With partner [] With parents

[] With partner & children [] With friends

[] Other, specify :

[] Retired

[] Student/Pupil

[] Other, specify :

[] Not known

[] No fixed abode

[] Not Known

[] Other, specify :

Section II Background Information

Police Officer’s report:

Recent history of drug use and other relevant information:

Was the deceased on prescribed psychoactive medication ? [] Yes

If yes, please list drugs:

1. See attached 4.

:2. 5.

:3. 6o

[] No [] Not known

Was the deceased a drug addict or known drug abuser? ’ Yes [] No [] Not known

The National Programme on Substance Abuse Deaths (np-SAD)

PCO000008-O013

Section III Details of Death

Date of death : 24 \ 1 \ 1998

Place of death : (tick one only)

[] Home

[] Place of work

[] Treatment centre

[] Other place, specify

[] Residential premises (e.g. hotel)

[] Street or highway

[] Educational institution

[] In custody

[]/Place of recreation/sport

IS]/ Hospital

Cause(s) of death (as given on the death certificate)

l(a) Bronehopneumonia

(b)

(c)

2 Severe Depression

Toxicology ~ ~ ~)

Please list drugs and alcohol present at post mortem (in order of importance, if known)

Drug/alcohol Level Drug/alcohol

B T U

1. 4.

B = Blood; T = Tissues; U = Urine

B

Level

T U

Section IV Coroner’s Verdict

Narrative Verdict

Section V Coroner’s Details

Coroner’s name: David Clark Horsley Date inquest completed: 18/03/2009

Jurisdiction: _._~0_~_o._.u_.t_.h_._&_._s~0_u_t._h_._E_a_s_~_._H_a_._m_p_s_.~!~e Office: Room T20

Signature: Code A i Date:

Please send completed form to: National Programme on Substance Abuse Deaths (np-SAD) International Centre for Drug Policy St George’s University of London FREEPOST LON 10141, London SW17 OBR

4th March 2010

For general enquiries: Tel 020 8725 2623 or Fax 020 8266 6494

PCO000008-0014

3.12

3.13

3.14

Drug Chart Analysis:

On 5t" January at transfer 16M), Mr Pittock is written up for the standard drugs that he was on in the.mental health ward including his Sertraline and Lithium (for his depression) D!azepam (for his agitation) Thyroxine for his hypothyroidism. The drug £hart also had Diamorphine 40 - 80 mgs subcut in 24 hours Hyoscine 200 - 400 micrograms subcut in 24 hours and-Midazol~m 20 - 40 mgs subcut in 24 hours. Midazolam 80 mg subcut in 24 hours written up but not dated and never prescribed. (18M)

On 10t" January, Oramorph 10 mgs per 5 mls is written up for 2.5 mls four hourly and prescribed on the evening of 10th and the morning of the

th th 11 . On the 11 Oramorph 10 mgs per 5 mls is written up to be given 2.5 mls 4 hourly 4 times a day with 5 mls to be given last thing at night. This is then given regularly between 11th and up to early morning on 15th January. This is a total daily dose of 30 mgs of Morphine (19M). The Lithium and Sertraline are crossed off after the 10th January.

Diamorphine 80 - 120 mgs subcut in 24 hours is written up on 1,1th January "as required" as is Hyoscine 200 - 400 micr, ograms.,in 24 - hours, Midazolam 40- 60’mgs in 24 hours. 80 mgs ~ef..Diamorphine together with 60 mgs of Midazolam are then started by syringe driver on the morning of the 15 January and re-started on both the mornings of the 16t" and 17th January..(18M). On 16th January Haloperidol 5 mgs- 10 mgs subcutaneous for 24 hours is written up, prescribed over 24 hours on both 16t" and 17t", 1 am not clear if this was mixed in the other syringe driver o.r was the "second pump" referred to in the nursing cardex. (20M and 27M)

PCO000008-0015

Diamorphine 12..0 mgs subcut in 24 hours is then prescribed on 18th January, together with Hy!oscine 600 mgs subcut in 24 hours. The drug charts (20M) show this starting on the morning of 17th January and at 08.30 hours. If this correct there may have been up to three syringe drivers running, one with Diamorphine 80 mgs, one with Diamorphine 120 mgs in and one with the Haloperidol. The reason for this confusion needs clarification, but is possibly a nursing error with the drug chart.

The subsequent drug charts all appear to be missing for the final 6 days, however the nursing notes (27M, 28M and 29) suggest that there was a fairly constant prescription of 120 mgs of Diamorphine 24 hours, Midazolam 80 mgs 24 hours, Hyoscine 1200 mgs, Haloperidoi 20 mgs and Nozinan 50 mgs. On the 20th there was no Haloperidol and the Nozinan was increased 100 mgs a day. This is still the prescription on 23rd January (27M).

Drug Oramorphine

Diamorphine

Midazolam

Diamorphine

Midazolam

Midazolam

Oramorphine

Oramorphine

Diamorphine

Date prescribed 10/01

?

11/01

11/01

? 16/01

11/01

11/Ol

18101

Prescribed as 10 mgs in 5 mls 2.5 mls, 4hrly oral Regular

Prescriber Barton

40 mgs SIC in Barton 24 hours Regular

NEW DRUG CHART 20 - 40 mgs SIC Barton in 24 hours Regular 80 - 120 mgs Barton SIC in 24 hours PRN 40 - 60 mgs Barton SIC in 24 hours PRN 80 .mgs SIC in Barton 24 hours PRN t0 mgs in 5 mls Barton Oral 2.5 mls 4 hourly Regular 10 mgs in 5 mls Barton Oral 5 mls nocte

120 mgs Barton SIC in .24 hours

Given 10/01 2200 11/01 0800 (nevercrossed out)

Never given or crossed

off

Never given or crossed off

15/01 ? 80 mgs 16/01 0815 80mgs 17/01 ? 80 mgs 15/01 ? 60 mgs 16/01 ? 60 mgs 17/01 ? 60 mgs Nevergiven

Regular doses 4 times a day until 0600 on 15/01 No further doses Not crossed off 11/01 - 15/01 2200 No further dos_es_ Not crossed off "17/01" 0830 120 mgs (probably 18/01 )

PCO000008-O016

Code A

PCO000008-O017

Leslie Charles PITTOCK

The Deceased was an Inpatient at Gosport War Memorial Hospital and was

receiving opioid medication by syringe driver at the time of death

Did the administration of any medication contribute more than

minimally or negligibly to the death of the deceased ?

If Yes ¯

2. Was that medication given for therapeutic purposes

Yes/No

If Yes ¯

3. Was that medication appropriate for the condition or symptoms

from which the deceased was suffering ? Yes/No

PCO000008-O018

Code A

PCO000008-O019

Gosport WMH

Narrative Verdicts

In all cases The deceased was an inpatient at Gosport War Memorial Hospital and was receiving Opoid Medication at the time of death.

PITTOCK The administration of medication did not contribute more than minimally or negligibly to the death of the deceased.

LAVENDER The administration of medication did contribute more than minimally or negligibly to the death. The medication was given for therapeutic purposes. That medication was appropriate for the condition of symptoms from which the deceased was suffering.

SERVICE The administration of medication did not contribute more than minimally or negligibly to the death of the deceased.

LAKE Ditto - As SERVICE above.

CUNNINGHAM The administration of medication did contribute more than minimally or negligibly to the death. The medication was given for therapeutic purposes. That medication was appropriate for the condition or symptoms from which the deceased was suffering.

PACKMAN The administration of medication did contribute more than minimally or negligibly to the death of the deceased. The medication was given for therapeutic purposes the medication was not appropriate for the conditions or symptoms from which the deceased was suffering.

WILSON Ditto - As PACKMAN above.

DEVINE Ditto - As PACKMAN above.

SPURGIN The administration of medication did not contribute more than minimally or negligibly to the death of the deceased.

GREGORY Ditto - As SPURGIN above

PC0000008-0020

Code A

PC0000008-0021

Code A

PC0000008-0022

Leslie Charles PITTOCK

The Deceased was an Inpatient at Gosport War Memorial Hospital and was

receiving opioid medication by syringe driver at the time of death

Did the administration of any medication contribute more than

minimally or negligibly to the death of the deceased ?

If Yes ’

2. Was that medication given for therapeutic purposes

Yes/No

If Yes ¯

3. Was that medication appropriate for the condition or symptoms

from which the deceased was suffering ? Yes/No

PCO000008-0023

INQUEST CHECKLIST

Name: Leslie Charles PITTOCK

Date Reported: 13.05.2008 DATE OPENED: 14.05,2008

Ref: 1002/08

By: RMB

INQUEST by RMB Time allocated: 6 weeks

Wednesday, 18 March 2009 at 10.00am in the Coroner’s Court in the Portsmouth Combined Courts Building, Winston Churchill Avenue, Portsmouth, POI 2EB

Jury: Yes Listing Office notified [] Room Booked []

F99/INQ PREPARED []

PRESS DETAILS:

Born: i_._.__C...o_._d._.e_.._A_._._j Lived at: Not yet known

Died at: Gosport War Memorial Hospital

HCC MEDIA UPDATED

Died on: 24.01.1996

Type of Inquest: Medical

ADJOURNED TO:

Date: ............. day,. ............................. Time: ............ to ............ By: ............

At: ..................................................................................................................................

AFTER INQUEST

VERDICT

[] Database Death Entry [] Register [] Drugs Form [] Other Form ......................................

[]Tape Recorded In File for .....................................................................................................

Other Inquests on Tape ..............................................................................................................

PCO000008-0024

Coroners Initial Sudden Death Report CO/1

Date Reported: 13/05/2008 Ref: Number 1002/08 Type of Case: Inquest Ng£ITI C :

Address:

Date of Birth:

Age:

Date of Death:

Place of Death:

Mortuary:

Removed By."

Funeral Directors:

General PracNdoner:

Reported By:

Reason for ReferrM:

Leslie Charles PTTOCK

Code A 82 Years.

24~ January 1996

GosportWar Memorial Ward:

Family

Hospital Consultant:

Family concerns Y/N

Brief History: Died in Gosport War Memorial. This has been subject of a lengthy police investigation.

Initials: Date: 13/05/2008

CAUSE OF DEATH:

la) lb) lc)

2)

Pathologist:

INQUEST CASES:

Date Opened .... Time: ...... Inquest Date: ..................... Time: .................

Adjournments: .......................................................................................................................................

Signed By: David Clark Horsley Coroner, Portsmouth South East Hampshire Date: 13~ May 2008

PCO000008-0025

Openin & Adjournment of an Inquest

Full Name of Deceased:

Sex:

Date of Death:

Place of Death:

Reported by: from: on:

Pathologist:

Leslie Charles PITTOCK

Male

24th January 1996

Gosport War Memorial

Family

Age: 82 years

Address:

Date of Birth:

Place of Birth:

Deceased’s Occupation:

Marital Status:

Maiden Name:

Name of Surviving Wife: Date of Birth: Occupation:

Married

CHILDREN UNDER 16 YEARS

Fathers Name: N/A Occupation:

Mothers Name: N/A Occupation:

Circumstances of Death: Died in Gosport War Memorial. This has been subject of a lengthy police investigation.

Deceased Identified by: Unknown

Evidence given by: Lisa-Jane JOHN Coroners Officer.

Inquest into the above named deceased opened and adjourned to enable further enquiries to be made, upon the order of."

HM Coroner, Portsmouth & South East Hampshire

Dated: 13th May 2008

PC0000008-0026

Opening & Adjournment of an Inquest

Full Name of Deceased:

Sex:

Date of Death:

Place of Death:

Reported by: from: on:

Pathologist:

Leslie Charles PITTOCK

Male

24th January 1996

Gosport War Memorial

Family

Age: 82 years

Address:

Date of Birth:

Place of Birth:

Deceased’s Occupation: ------

Marital Status: Married

Maiden Name:

Name of Surviving Wife: Date of Birth: Occupation:

CHILDREN UNDER 16 YEARS

Fathers Name: N/A Occupation:

Mothers Name: N/A Occupation:

Circumstances of Death: Died in Gosport War Memorial. This has been subject of a lengthy police investigation.

Deceased Identified by: Unknown

Evidence given by: Lisa-Jane JOHN Coroners Officer.

/nquest into the above named deceased opened and adjourned to enab/e further enquiries to be made, .upon the order of." ,

, � de A Dated: 13th May 2008

PCO000008-0027

David C. Horsley LLB Her Majesty’s Coroner for Portsmouth and South East Hampshire

Coroner’s Office Room T20 The Guildhall Guildhall Square Portsmouth PO1 2AJ

Fax: 023 9268 8331

15 May 2008

Dear Mrs Wiles

Leslie Charles Pittock Deceased:

Please note that on 14 May 2008 I opened an Inquest into the death of Mr Pittock.

I will continue to keep you informed of key stages of the Inquest process.

If you require a Coroner’s Interim Death Certificate on Mr Pittock for any purpose, please contact me.

Yours sincerely

David C Horsley Tel: 023 9268 8326 Emaili, .............................................................................................. Code A .

Hampshire County Council

Portsmouth CITY COUNCIL

PCO000008-0028

Mrs L Wiles

15 May 2008

Dear Mrs Wiles

Leslie Charles Pittock Deceased:

Please note that on 14 May 2008 I opened an Inquest into the death of Mr Pittock.

I will continue to keep you informed of key stages of the Inquest process.

If you require a Coroner’s Interim Death Certificate on Mr Pittock for any purpose, please contact me.

Yours sincerely

David C Horsley Tel: 023 9268 8326 Email:[~ ....................................... -~Sa;~-;~ ........................................ i

PCO000008-0029

David C. Horsley LLB Her Majesty’s Coroner for Portsmouth and South East Hampshire

Code A

21 April 2008

Dear Mrs Wiles

~ 9 APR

Coroner’s Office Room T20

The Guildhall Guildhall Square Portsmouth eol 2aJ

Fax: 023 9268 8331

As you will no doubt be aware from Hampshire Police, they have passed to me details of a number of deaths that occurred some years ago at Gosport War Memorial Hospital, including details of the death of Mr Pittock.

I have decided to open Inquests to look into how ten of these deaths occurred. One of these Inquests will concern Mr Pittock.

The Police investigations into the deaths were very complex and took a number of years to complete. When their files were given to me there was an additional complication before I could get to the present stage; seven of the ten people concerned had been cremated and I had, by law, to obtain the formal consent of the Ministry of Justice to open Inquests on their deaths. This consent has now been given and I am in a position to make further progress.

To assist me in opening the Inquests I should be most grateful if you could kindly complete the enclosed questionnaire in relation to Mr Pittock and return it to me as soon as you can. I enclose a stamped addressed envelope for your reply.

Once the Inquests have been opened, decisions will need to be taken about the logistics of organising ten complex Inquests. Issues such as who are to be called as witnesses, how long the Inquests will take, and where will they be held, will have to be resolved. As you will appreciate, it takes time to sort out these matters and, therefore, further progress will not happen overnight. I will,

Hampshire County Council

Portsmouth CITY COUNCIL

PCO000008-0030

however, do my best to keep you informed about key developments from your point of view.

The Inquests will put a great deal of pressure on the resources available to me and, of course, I must maintain an effective level of service as regards all the other deaths that I have to deal with at the same time as preparing for and holding these Inquests. Consequently, it has been agreed that these Inquests will be conducted on my behalf by another very experienced Coroner acting as my deputy - rather like the way Inquests into service deaths in the Middle East are being dealt with at the moment. That Coroner is to be Mr A M Bradley who is HM Coroner for North Hampshire. However, all administrative arrangements for the Inquests will be handled by my office and any correspondence about them - even when addressed to Mr Bradley - should, please, be sent to my office.

If I can assist you any further at this stage, please do not hesitate to contact me.

Yours sincerely

David C Horsley Tel: 023 9268 8326 Email:i ..................................... ~~-~1~-~ .................................... i

Enc

PC0000008-0031

LESLIE CHARLES PITTOCK DECEASED

1. Full Name (if different from above):

2. Maiden Name (if appropriate):

3. Last Permanent Address:

4. Date of Birth:

5. Place of Birth:

6. Last Occupation Before Retirement (if known):

7. Marital Status:

8. Name of Surviving Spouse (if applicable):

PC0000008-0032

Coroners Initial Sudden Death Report

Date Reported: 1;3/05/2008

N£tlTl e :

Address:

Date of Birth:

Age:

Date of Death:

Place of Death:

Ref: Number 1002/08

Mortuary:

Removed By:

Funeral Directors:

General Practitioner:

Reported By:

Reason for Referral’.

Leslie Charles PTTOCK

~o~- ~

24~ January 1996

GosportWar Memorial Ward:

co/1 Type of Case: Inquest

Family

Hospital Consultant:

Family concerns Y/N

Brief History: Died in Gosport War Memorial. This has been subject of a lengthy police investigation.

Initials: Date: 13/05/2008

CAUSE OF DEATH:

la) lb) lc)

2)

Pathologist:

INQUEST CASES:

Date Opened . Time: ..........- .... Inquest Date: ..................... Time: .................

Adjournments: ............................................ , ..........................................................................................

Signed By: David Clark Horsley Coroner, Portsmouth South East Hampshire Date: 13~ May 2008