Source · Prevention of Future Deaths
Peter McCarthy
Ref: 2024-0679
Date: 10 Dec 2024
Coroner: Caroline Topping
Area: Surrey
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.
Date
10 Dec 2024
56-day deadline
4 Feb 2025
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner is concerned that Care4U Healthcare lacks a protocol to prevent clients who have fallen from being given anticoagulant medication without medical oversight, as staff cannot identify contraindications with blister-packed medications.
View full coroner's concerns
Following the inquest Care 4 U have put in place steps to ensure staff do not leave clients alone whilst they wait for ambulances.
However, I remain concerned that:
1. On her arrival the carer offered Mr McCarthy his daily medications, which included an anticoagulant. He refused to take it. Following the conclusion of the inquest I sought information from Care4U Healthcare as to what, if any, protocol they have to ensure that clients who have fallen are not given anticoagulant medication without medical oversight. I have been told that medication comes in blister packs and the staff would not know if any medication was contra indicated after a fall. To date no protocol has been provided to the Court to deal with this type of situation.
However, I remain concerned that:
1. On her arrival the carer offered Mr McCarthy his daily medications, which included an anticoagulant. He refused to take it. Following the conclusion of the inquest I sought information from Care4U Healthcare as to what, if any, protocol they have to ensure that clients who have fallen are not given anticoagulant medication without medical oversight. I have been told that medication comes in blister packs and the staff would not know if any medication was contra indicated after a fall. To date no protocol has been provided to the Court to deal with this type of situation.
Report sections
Investigation and inquest
An Investigation was commenced on the Eleventh December 2023, and an Inquest opened on the Fourteenth December 2023, into the death of Peter McCarthy. The Inquest concluded on the Ninth October 2024.
Peter McCarthy died on the 30th November 2023 from heart failure and pneumonia.
The conclusion was that he died by Accident.
Peter McCarthy died on the 30th November 2023 from heart failure and pneumonia.
The conclusion was that he died by Accident.
Circumstances of the death
Peter McCarthy fell from his wheelchair at home on the evening of the 25th November 2023 when his wheelchair flipped over a slight ridge between the bathroom and corridor. He was not found until the following morning by his carer. She called an ambulance. She left the premises. Shortly thereafter a district nurse attended and made a further call to the ambulance which resulted in a quicker categorisation of the response. He was taken by ambulance to East Surrey Hospital and found to have sustained rib fractures and a subdural hematoma. He was given appropriate care, but he deteriorated and died on the 30th November 2023 from heart failure and pneumonia.
Copies sent to
Care Quality Commission
Similar PFD reports
Report details
- Reference
- 2024-0679
- Date of report
- 10 December 2024
- Coroner
- Caroline Topping
- Coroner area
- Surrey
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Feb 2025 (stated in the report).
Sent to
- Care4U Healthcare
Non-response list
The Chief Coroner has confirmed the following did not respond within the required period:
- Care4U Healthcare