Source · Prevention of Future Deaths
John Andrews
Ref: 2014-0426
Date: 3 Oct 2014
Coroner: Elizabeth Gray
Area: Milton Keynes
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted that Mr Andrews was discharged from hospital without his family being informed, leading to him arriving home alone with no immediate care in place, and subsequently falling.
Date
3 Oct 2014
56-day deadline
28 Nov 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted that Mr Andrews was discharged from hospital without his family being informed, leading to him arriving home alone with no immediate care in place, and subsequently falling.
View full coroner's concerns
(1) Mr Andrews was admitted to Milton Keynes Hospital on 31* March 2014 following a fall: Following detailed discussion with Mr Andrews was discharged from hospital. Mr Andrews was insistent that he wanted i0 be discharged. lagreed reluctantly, but decided that a discharge be in Mr Andrews best interest given his insistence upon leaving and returning home, plus his unwillingness to remain in Milton Keynes Hospital.
(5) Upon discharge the_plan agreed withL was to implement a care package to assist from artery due very would
Mr Andrews at home (6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance_ Fomal care arrangements were not arranged until 2-3 days later (Monday). It was too late_ as Mr Andrews had fallen when home alone on the first and was found on the floor by his son, who happened to phone his father; to be told he was at home (8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home t meet their needs
(5) Upon discharge the_plan agreed withL was to implement a care package to assist from artery due very would
Mr Andrews at home (6) On the day of discharge Mr Andrews family were not advised of his discharge. As a result, Mr Andrews arrived home by ambulance alone, the heating was not on and there were no groceries. Importantly the family were not present to give any physical assistance_ Fomal care arrangements were not arranged until 2-3 days later (Monday). It was too late_ as Mr Andrews had fallen when home alone on the first and was found on the floor by his son, who happened to phone his father; to be told he was at home (8) Discharge arrangements for frail, vulnerable patients must ensure that patients can only be sent home if there is appropriate care in place at home t meet their needs
Report sections
Investigation and inquest
On 02/06/2014 commenced an investigation into the death of John Andrews, 76 The investigation concluded at the end of the inquest on 26 September 2014. The conclusion of the inquest was Accident Fell at home on 31st March and again on 25th April. Hospital admission followed and subdural haematoma diagnosed leading to pneumonia and death on Ist June 2014. Pneumonia Sub-Dural Haemorrhage Recurrent Falls Stroke Previous Myocardial Infarction
Circumstances of the death
PMH: Stroke, occipital lobe & MCA infarct which has affected his visual field resulting in recurrent falls at home Previous MI; CABG in 1992.31/03/14 MKH MKH due to chronic subdural secondary to a fall, discharged stroke unit 25/04/14 to home. At home fell again and readmitted to MKH during the early hours of the morning due to head injury. CT scan of brain shows small sub acute subdural haemorrhage (no significant changes from previous scan) , chronic occipital infarct. CT of abdomen showed right internal iliac aneurysm: Pt sat in chair; tried to stand & fell again . Moved to stroke ward. Confused & agitated 02/05/14 Fell again , no apparent injuries, 05/05/14 1 to care so as to prevent him getting out of bed or chair. 13/05/14 Becoming chesty, signs of chest infection: 19/05/14 Change of medication to past cardiac history, pt developed a twitch which was thought to be precursor to fits and So given medication to control it, Pt refusing diet, fluids limited. NG tube inserted, family informed of poor prognosis, DNR signed, treatment continues, pt continues to decline, RIP
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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Report details
- Reference
- 2014-0426
- Date of report
- 3 October 2014
- Coroner
- Elizabeth Gray
- Coroner area
- Milton Keynes
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: 28 Nov 2014 (estimated from the report date).
Sent to
- Milton Keynes Hospital