Source · Prevention of Future Deaths

Thomas Farrell

Ref: 2015-0273 Date: 14 Jul 2015 Coroner: Stephanie Haskey Area: Nottinghamshire Responses identified: 0 / 1 View PDF

The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.

Date 14 Jul 2015
56-day deadline 9 Sep 2015
Responses identified 0 of 1
Care Home Health related deaths

Coroner's concerns

AI summary
The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
View full coroner's concerns
1. That the Home did not know the true extent of the prescription drugs which were indicated for Mr Farrell while he was a resident, having not approached Mr Farrell’s GP for a full record. The result of this was that the prescription drugs aspirin, senna, doxacil and omeprazole were not given. Whilst in the event this did not cause or contribute to his death on 16th July 2014, the risk of such an omission causing death in other circumstances is clear.

Report sections

Investigation and inquest
On 15th May 2015 an Inquest was commenced into the death of Thomas Farrell, who died on 16th July 2014 at Queen’s Medical Centre, Nottingham of Respiratory Failure as a result of Bronchopneumonia as a result of Emphysema. A Conclusion of Natural Causes was recorded.
Circumstances of the death
Mr Farrell died whilst a resident at Springfield Care Home, Nottingham. Shortly before his death he became unwell with a chest infection and was visited by his GP, who prescribed antibiotics, which were given. The Home had taken responsibility for the administration of Mr Farrell’s prescription medications, including those he entered the home with, as well as the antibiotics. His condition worsened and he was admitted to hospital in the early hours of 16th July 2014, where he died the same day.
Copies sent to
2. : The Care Quality Commission and Nottingham City Council Safeguarding Adults

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Report details

Reference
2015-0273
Date of report
14 July 2015
Coroner
Stephanie Haskey
Coroner area
Nottinghamshire

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: 9 Sep 2015.

Sent to

Springfield Care Home

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