Source · Prevention of Future Deaths
Ronald Bonfield
Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Date
11 Sep 2015
56-day deadline
6 Nov 2015 est.
Responses identified
0 of 4
Coroner's concerns
Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
View full coroner's concerns
The matters of concern as follows: (1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield's death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient's INR testing) is not uniform andlor implemented across all of the Health Boards Level 4 Accredited GP practices (2) The practices and procedures implemented by Practice 1 , Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitoredlunactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned (3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield's, where delegated INR testing has not been done leading_to un-monitored over anti-coagulation
Report sections
Investigation and inquest
On the 3" October 2014, commenced an investigation into the death of Mr Ronald Francis Bonfield. The investigation concluded at the end of the inquest on the g"h September 2015. The conclusion of the inquest was 'The deceased took Warfarin as an anti-coagulant: On the 29"h September 2014 he sustained a head injury whilst at home when a chair he sat on toppled backwards: He was diagnosed with a subdural haematoma: He had sustained this injury at a time when he was over anti-coagulated: His INR levels were not being monitored as required: His untreatable condition deteriorated and he passed away at Prince Charles Hospital on the 2nd October 2014 at 1Opm'_
Circumstances of the death
Whilst at home on 29th September 2014, the deceased sustained a head injury when he struck his head on the handle of a kitchen door On 1st October 2014 he was admitted to Prince Charles Hospital. A head injury was diagnosed, but he was not for active surgical intervention He deteriorated and died at Prince Charles Hospital on 2rd October 2014
Action should be taken
In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action in the area of: Ensuring that all level 4 accredited GP practices across the Cwm Taf Health Board area follow the (monitoring) practices & procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield's death
Similar PFD reports
Related inquiry recommendations
Report details
- Date of report
- 11 September 2015
- Coroner
- Graeme Hughes
- Coroner area
- Powys
Responses identified
Responses identified
0 of 4
4 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Nov 2015 (estimated).
Sent to
- England and Wales
- Cwm Taf Morgannwg University Health Board
- National Assembly for Wales
- Practice 1, Keir Hardie Health Park