Source · Prevention of Future Deaths

James Edward Mansfield

Ref: 2013-0288 Date: 10 Oct 2013 Coroner: Mrs Cheney Area: Cambridgeshire (South and West) Responses identified: 0 / 1 View PDF

Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.

Date 10 Oct 2013

56-day deadline 3 Jan 2014

Responses identified 0 of 1

Community health care and emergency services related deaths

Coroner's concerns

AI summary

Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.

View full coroner's concerns

(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that that the hospital post discharge letters to your surgery. This was not received received until 28th February 2013 by which time Mrs Mansfield had called requesting stronger pain killers. The discharge summary was only reviewed by a doctor on 6 March. You stated that only if a patient was admitted to hospital would their discharge letter get prompt attention. There was no apparent method for differentiating between discharge summaries which involved serious injuries and those which did not.

(2) When telephoned the surgery, complaining of Mr Mansfield’s pain, strong pain killers were prescribed but he was not seen despite a long history of lung and chest complaints, multiple rib fractures and treatment with warfarin.

Report sections

Investigation and inquest

On 14th March 2013 I commenced an investigation into the death of James Edward Mansfield whose date of birth was 15 February 1943. The investigation concluded at the end of the inquest on 10 October 2013. The medical cause of death was: 1a) Right haemothorax 1b) Multiple rib fractures 1c) Fall
2) Atrial fibrillation with anticoagulation Hypertensive heart disease Hepatic cirrhosis

The conclusion of the inquest was that Mr Mansfield died as a result of bleeding into his chest due to rib fractures sustained in a fall, coupled with treatment with warfarin.

Circumstances of the death

Mr Mansfield had a long history of lung related complications and had multiple occurrences of pneumonia. He was on warfarin. On 25 February2013 he fell at this home. He saw the GP who referred him to the x-ray department at Addenbrookes. An x-ray showed four displaced rib fractures. He was reviewed in the A+E where he said he was comfortable and he was discharged to the care of his GP, with a leaflet. On 27 February called the GP advising of Mr Mansfield’s pain and she requested stronger painkillers. These were prescribed but he was not seen. The discharge summary was received by the GP Surgery on 28th February and was reviewed on 6 March. On 8 March Mr Mansfield called for the GP. He was admitted to Addenbrookes and a chest x-ray revealed a large right haemothorax. Mr Mansfield passed away at 18.55 on 9 March 2013.

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Report details

Reference: 2013-0288
Date of report: 10 October 2013
Coroner: Mrs Cheney
Coroner area: Cambridgeshire (South and West)

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: 3 Jan 2014.

Sent to

Nuffield Road Medical Centre

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.