James Stewart

On April 2014 commenced an Investigation into the death of James Duncan STEWART The Investigation concluded at the end of the Inquest on 03 November 2014: The conclusion ofthe inquest was a NARRATIVE CONCLUSION: The deceased was admitted to Manton Heights Care Home; Woodlands; Bedford, on the 4th February 2014. He suffered Parkinson's Disease and due to systems failure, the time that he came into the home, he was not given his medication because the Co-Careldopa was not included in his list of medication that was requested from the General Practitioner_ He deteriorated and was admitted to Bedford Hospital on the 12th April 2014 with decreased mobility and responsiveness He died at Airedale Nursing Home, 44 Park Avenue, Bedford on the 21st April 2014 CIRCUMSTANCES OF THE DEATH James had been resident at Manton Heights Nursing Home since 04 February 2014 having come from sheltered housing where he was not coping: Whilst at Senior Coroner: The Court House; Woburn Street AMPTHILL; Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 4HR httpil aged 84: from from drug

Manton Heights, it appears that he was not given his Parkinson Disease medication and this was only realised once he was admitted to Bedford Hospital South on April 2014 with decreased mobility and responsiveness James was discharged from Bedford Hospital South to the Airedale Nursing Home for end of life care. He sadly died on the April 2014. His previous medical history was Parkinson's Disease, Dementia, Atrial Fibriliation Peripheral Vascular Disease and Knee replacement CORONERS CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows: (1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient's Nursing Home the details are not checked with the previous Practice. Such system would have highlighted the fact that Mr. Stewart's Co-Careldopa medication had not been included (2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon unqualified staff from the Home. also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is in place. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe _ have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 days of the date of this Report; namely by 29 January 2015. I, the Coroner, may extend the period. Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed_ COPIES and PUBLICATION Ihave sent a copy of my Report to the Chief Coroner and to the following Interested Persons: Senior Coroner; The Court House Woburn Street AMPTHILL, Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 Wing Wing They put you duty

Family The Airedale Nursing Home Manton Heights Nursing Home (Ranc Care Group) I am also under a to send the Chief Coroner a copy ofyour Response The Chief Coroner may publish either o both in complete Or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful Or of interest: You may make representations to me, the Coroner; at the time of your response, about the release O the publication of your Response by the Chief Coroner. Dated 04 December 2014 M X |hum YA THOMAS R OSBORNE Senior Coroner for Bedfordshire and Luton Senior Coroner, The Court House Woburn Street AMPTHILL Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 duty: '@OHONEA DSHIRE AN)

James had been resident at Manton Heights Nursing Home since 04 February 2014 having come from sheltered housing where he was not coping: Whilst at Senior Coroner: The Court House; Woburn Street AMPTHILL; Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 4HR httpil aged 84: from from drug

Manton Heights, it appears that he was not given his Parkinson Disease medication and this was only realised once he was admitted to Bedford Hospital South on April 2014 with decreased mobility and responsiveness James was discharged from Bedford Hospital South to the Airedale Nursing Home for end of life care. He sadly died on the April 2014. His previous medical history was Parkinson's Disease, Dementia, Atrial Fibriliation Peripheral Vascular Disease and Knee replacement

(1) There did not appear to be any system whereby when a new GP Practice is requested to prescribe medication from a patient's Nursing Home the details are not checked with the previous Practice. Such system would have highlighted the fact that Mr. Stewart's Co-Careldopa medication had not been included (2) It was felt by those giving evidence from the GP Practice, and from the two Nursing Homes, that the correct medication to be prescribed should be a matter for the General Practitioner to confirm rather than relying upon unqualified staff from the Home. also felt that the Clinical Commissioning Group were the obvious body to ensure that a robust and consistent system is in place. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe _ have the power to take such action. YOUR RESPONSE You are under a to respond to this report within 56 days of the date of this Report; namely by 29 January 2015. I, the Coroner, may extend the period. Your response must contain details of action taken Or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed_ COPIES and PUBLICATION Ihave sent a copy of my Report to the Chief Coroner and to the following Interested Persons: Senior Coroner; The Court House Woburn Street AMPTHILL, Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 Wing Wing They put you duty

Family The Airedale Nursing Home Manton Heights Nursing Home (Ranc Care Group) I am also under a to send the Chief Coroner a copy ofyour Response The Chief Coroner may publish either o both in complete Or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful Or of interest: You may make representations to me, the Coroner; at the time of your response, about the release O the publication of your Response by the Chief Coroner. Dated 04 December 2014 M X |hum YA THOMAS R OSBORNE Senior Coroner for Bedfordshire and Luton Senior Coroner, The Court House Woburn Street AMPTHILL Bedfordshire MK45 2HX Tel 0300-300-6559 Fax 0300-300-8267 duty: '@OHONEA DSHIRE AN)