Ethel Smith Leese

(1) There was one matter of concern which relates to the monitoring of Mrs Leese’s warfarin levels. The move to the care home required Mrs

Leese to be changed to a different GP practice. The checking by the hospital of Mrs Leese’s address (including the address for posting for the yellow booklet) appears to have been fairly chaotic. Her address on the paperwork seems to have remained unchanged, there appears to have been doubt as to whether Cumberland House Medical Practice in Stone or the Penkridge Medical Practice (covering Dunston) were her GPs practice and indeed on one occasion information was sent to the wrong GP practice in Stone (Mansion House). It may be that Mrs Leese was initially considered to be a temporary resident at the care home in Dunston but I wonder if there is a possibility to record addresses better. Possibly this may not just apply in the Haematology Department but in the hospital as a whole. Whilst this may not have been directly relevant in this case it could be significant in other deaths.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 October 2013. 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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (son), Longridge Care Home at Dunston, at Cumberland House Medical Practice in Stone, at Penkridge Medical Practice, Mr Derek Winter HM Senior Coroner for Sunderland and The Department of Health, Whitehall, London.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a 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 or the publication of your response by the Chief Coroner.

Yours sincerely

Andrew A Haigh HM Senior Coroner Staffordshire (South)