Philip Ashton

On 20th October 2017 commenced an investigation into the death of Philip David Ashton,
45. The investigation concluded at the end of the inquest on 23"d April 2018. The narrative conclusion of the inquest was: The deceased was administered warfarin in error on 13th, 14th, and 15th October 2017. On the morning of the 17th October 2017 he was found on the floor of his room at Mallard House, Milton Keynes, bleeding from his arteriovenous graft in his left thigh. There was no attempt to stop the bleeding until the paramedics arrived on the scene and tourniquet: The delay resulted in a missed opportunity to prevent the hypovolaemic shock and the medication error contributed to the serious degree of bleeding: He was stabilised and transferred to Milton Keynes Hospital where he died at 12.37 pm.

The deceased was a resident of Mallard House Milton Keynes_ He attended hospital three times a week for dialysis. He had an arteriovenous graft on his left thigh. On the 13"h , and 15th October 2017 the deceased was administered warfarin in error. He was found in his room on the 17h October 2017 bleeding from his graft. The ambulance attended and were surprised that no attempt had been made by the staff to resuscitate or stop the bleeding_

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