Source · Prevention of Future Deaths

Hilda Harris

Ref: 2015-0161 Date: 24 Apr 2015 Coroner: Sarah-Jane Richards Area: Powys, Bridgend & Glamorgan Valleys Responses identified: 1 / 2 View PDF

The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.

Date 24 Apr 2015

56-day deadline 19 Jun 2015 est.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.

View full coroner's concerns

(1) The current booking system for community INR testing is unreliable with scope for appointments not being transferred from one set of papers to another: (2) Where an omission occurs, the notification system (by the family or carers) also appears unreliable:

Responses

1 respondent

University Health Board

16 Jun 2015 PDF

Action Taken

The University Health Board has developed and implemented a Corrective Action Plan for Improvement, with actions taken forward by the Primary Community & Localities Directorate. (AI summary)

View full response

Dear Dr Richards, Re: Regulation 28 Report Hilda Harris (died 4.1.2015) I refer to your e mail correspondence sent on April 2015, enclosing the Regulation 28 report, which details the areas of concern following your conclusion of the inquest on 17th April 2015 touching on the death of Mrs Hiilda Harris on 4th January 2015. Please be assured that the Health Board has taken this matter extremely seriously, has learnt lessons following investigation and the matters raised at the inquest into the circumstances. Comprehensive and robust action has been taken to minimise the risk of any recurrence 1_ Action taken to plan and monitor improvements A corrective Action Plan for Improvement was developed to capture the Health Boards comprehensive response; this is attached. 2 Actions implemented I can confirm that the actions have been taken forward by the Primary Community & Localities Directorate. The progress made is reflected in the plan as attached: I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigations into the care provided to Mrs Harris, and that effective action has now been taken to prevent future deaths: [would like to convey once again my deepest sympathy and sincere apologies to Mrs Harris' family for the failings identified. 27th

GIG Bwrdd lechyd Prifysgol cyMRu Cwm Taf NHS University Health Board WALES If you require any additional information or clarification please do not hesitate to contact me:

Report sections

Investigation and inquest

On the 16th January, 2015 commenced an investigation into the death of Mrs; Hilda May Harris The investigation concluded at the end of the inquest on the 17"h April; 2015. The conclusion 0f the inquest was 'natural causes exacerbated by prescribed medication'

Circumstances of the death

Mrs, Harris (86 years) suffered a previous myocardial infarction cerebral vascular accident: She aiso suffered from gout In or around October 2014 her Consultant' prescribed Warfarin and in consequence , Mrs Harris' INR feaedoloere monitored bytnereomibenity @tfatrictanurseCeam albeit;, dose adjustments were the responsibility of the Royal Glamorgan Hospital: In December 2014, Colchicine Allopurinal medications were prescribed to treata flare up of Mrs Harris' gout As either drug could affect the metabolism of Warfarin; an additional INR check was requested by the hospital for the 30.12.14 Although the request was received by the District Nurses' office; it was not transferred from one sheet of papers to another: In consequence, the INR test was not undertaken: Mrs. Harris' daughter; had been warned by the pharmacist of the of INR monitoring when combining Allopurinal with WarfarinThuswhen the DistoiceNce@' failed torurderakeeheOVR testyas arranged by the hospial contacted the GP surgery to advise of the omission: This message, although noted by surgery, Was not received or not acted upon by the Community District Nurses On the 04.01.15, Mrs Harris suffereda cerebral infarction with an intra-cerebral haemorrhage. Pathologist attributed the extensive bleed to elevated levels of Warfarin and and the

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 a dependable system of booking INR testing with the Community District Nurse team is established; and Ensuring a dependable system for communication between patients and their community District Nurses:

Copies sent to

Jane Richards HM Assistant Coroner

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0161
Date of report: 24 April 2015
Coroner: Sarah-Jane Richards
Coroner area: Powys, Bridgend & Glamorgan Valleys

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Jun 2015 (estimated).

Sent to

Cwm Taf University Health Board

National Assembly for Wales

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.