Source · Prevention of Future Deaths

Harold Goulding

Ref: 2016-0248 Date: 14 Jul 2016 Coroner: Nadia Persaud Area: London (East) Responses identified: 1 / 1 View PDF

Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.

Date 14 Jul 2016

56-day deadline 8 Sep 2016 est.

Responses identified 1 of 1

Care Home Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner community pharmacist therefore continued to provide reports to the old GP_ The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home_ The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews; considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving: It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared.

Responses

1 respondent

Orchard Care Homes Other

7 Sep 2016 PDF

Action Taken

The care home created a handover document for sharing new resident information with GPs, and implemented protocols to ensure nurses accompany GPs on rounds to discuss medication charts and care plans. (AI summary)

View full response

Dear Mrs Persuad RE: Alexander Court The Late Mr Harold Goulding The late Mr Harold Goulding was an 86 year old man admitted to Alexander Court Care Centre from Queens Hospital on the 28th October 2015 with the following Medical History: Heart Failure, Atrial Fibrillation, Stroke, left eye closed, Difficulty in breathing, Prostate Cancer , Type 2 Diabetes, Postural Hypotension and Pacemaker in situ; On 2nd November 2015 Mr Goulding's International Normalized Ratio was checked at Alexander Court Care Centre by from Barking & Dagenham PCT Anticoagulant Clinic (Contact No:
02085946188. Mr Goulding suffered a fall in early hours of 5th November 2015. He was seen by the GP, from Porters Avenue Surgery for post fall checks and initial assessment as a new resident and advised the Home to continue with the care as Mr Goulding was stable: Mr Goulding was observed throughout the and there were no significant changes in his condition: The GP was not aware that the late Mr Goulding was on Warfarin therapy and there was no record of assessments for a head injury: On the 6th November 2015 at around 15.01hrs, Mr Goulding suffered a second fall, He was found lying on the crash mattress at the side of his bed in his room: An ambulance was called immediately as Mr Goulding was complaining of breathlessness and swelling was noted around his neck; When the ambulance arrived took Mr Goulding to the hospital for further treatment; Whilst in hospital, a CT Scan was carried out on 7th November 2016. The scan confirmed an acute on chronic subdural haematoma; On the morning of 10th November 2016, Mr Goulding suffered a seizure, followed by a cardiac arrest and passed away in the care of the NHS. The Home Manager, Deputy Manager and Clinical Lead have held meetings with all the Nurses employed by Alexander Court: The purpose of this meeting was to discuss the incident with the late Mr Goulding and lessons learnt to prevent similar occurrences_ Daily meetings have been into place with Nursing staff to ensure that communication is paramount for the daily care of the residents and working with outside Professionals. A protocol document has been created to work alongside the policy of Working with Professionals, to enable better working communications with the Home staff and outside professionals. The Hamlet; Hornbeam Park, Harrogate HG2 8RE Tel: 01423 859859 Fax: 01423 859860

INVESTOR IN PEOPLE OrchardCareHomes com (Holdings) Ltd Registered in England no.6061481,Tri-Care Ltd Registered in England no.2235823, OrchardCareHomescom Ltd Registered in England no.5245993 , OrchardCareHomes com (2) Ltd Registered in England no.6177993,OrchardCareHlomes com (3) Ltd Registered in England no.6883079, OrchardCareHlomes com Ltd, Registered in England no.6881971, OrchardCareHomes com (5) Ltd Registered in England no.6882622, OrchardCareHomescom (6) Ltd Registered in England no.6881997 , OrchardCareHomes com (7) Ltd, Registered in England no.08370121, Cherry Health Care Ltd Registered in England no. 04216820, Loxley Healthcare Ltd Registered in England no. 04484936 Case (dlec the day they put the

RCHA RD"

When the GP visits the Home to attend to the resident's needs, the Nurse on accompany the GP on his rounds and go through the medication administration charts and care plans to ensure all information is shared where necessary: A handover document for use with new resident's details has been created to ensure relevant information is shared with the new GP where required. protocols that have been put into place, will be followed up by the Home Manager regularly:

Report sections

Investigation and inquest

On the 13lh November 2015 / opened an investigation into the death of Mr Harold Goulding: The investigation concluded at the end of the Inquest on the 13" July 2016_ conclusion of the Inquest was a narrative conclusion _ Mr Harold Goulding suffered 2 falls in his care home on the 5th and 6/h November 2015. He was admitted to hospital on the 6/h November 2015 where end stage heart failure and an acute on chronic subdural haematoma were diagnosed. On the 10h November 2015 he suffered a seizure from which he did not recover: The most likely cause of the fatal seizure was the trauma of the falls and consequent head injury:

Circumstances of the death

Mr Goulding suffered a fall at the Alexander Court Care Centre in the early hours of the 5"h November 2015. He was seen by a GP on 5 November 2015 who checked him for fractures_ The GP was not aware that Mr Goulding was on warfarin therapy and there was no record of any assessment for a head injury. The GP had not received reports from the anti-coagulation clinic and he did not check the Care Home's medication administration record. Mr Goulding suffered a second fall on the 6"h November 2015. He was taken to hospital following the second falll The main clinical concerns at this time were of shortness of breath, swollen neck and swollen armsllegs The initial impression upon attendance to hospital was of end stage heart failure. A CT scan carried out on the 7lh November 2015 confirmed an acute on chronic subdural haematoma. Mr Goulding remained in hospital and was stable until the 8lh November 2015 when it was noted that he was suffering from swallowing difficulties_ His family also noted an increase in his level of confusion at this time_ On the morning of the i0"h November 2015 he suffered from a seizure. Despite anti-epileptic medication and management of his airway, he suffered a cardiac arrest Life was pronounced extinct at 09.46 on the 10lh November 2015, At the Inquest the cause of death was found to be 1a cardiac arrest 1b seizure Ic fall, head injury and subdural haematoma (on warfarin therapy) . 2 congestive cardiac failure; type 2 diabetes and hypercholesterolemia. The

Action should be taken

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

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Shared signals

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Report details

Reference: 2016-0248
Date of report: 14 July 2016
Coroner: Nadia Persaud
Coroner area: London (East)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Sep 2016 (estimated).

Sent to

Alexander Court Care Central

Source links

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Data: judiciary.uk under OGL.