Harold Mullins

On the 18"h January commenced an investigation into the death of Harold Mullins aged
92. The investigation concluded at the end of an inquest on the 18" April 2017. conclusion of the inquest was that of "natural causes

The deceased was admitted to the Royal Glamorgan Hospital on the 3" January having sustained a fall or collapse at his home address No detaii was known as to what may have caused that: On admission to hospital he was found to have a fracture to the left neck of femur; He had a raised INR level and an Acute Kidney Injury and therefore' surgery was delayed until the 5lh January. On the afternoon of that he underwent surgical repair of the fracture to his hip. After surgery his standard observations (NEWS scores) were noted to be raised. In early parts of the evening continued to rise and assistance was sought by the nursing staff from one of clinical team treating Mr Mullins_ The Doctor indicated that "they were not concerned" as Mr Mullins had undergone surgery and did not examine him. The matter was then further escalated when his blood pressure fell further and no clinician was available to examine him The initial contact with the treating clinician appears to have been at 2010 hours and the matter escalated again at 2145. On that occasion advice was given for fluids to be administered but again the treating clinician did not see Mr Mullins. By the time the clinician did see Mr Mullins he had suffered a cardiac arrest ad despite efforts could not be resuscitated.

In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action.