Raymond Claude Woodhouse · Prevention of Future Deaths report

On 20 October 2020, I concluded an inquest into the death of Raymond Claude Woodhouse who died in RCHT on 11 February 2019. The medical cause of death was recorded as:

1a) Bronchopneumonia
1b)
1c)
II) Parkinson’s disease, Infected bursitis (operated), Osteoarthritis of the knee (operated)

I recorded a Narrative Conclusion that Mr Woodhouse died from a known complication (infection) of a necessary surgical procedure (total knee replacement.)

Mr Woodhouse suffered with severe Parkinson’s disease. He also had debilitating pain in an arthritic left knee. The family obtained specialist advice about the risks of a knee replacement procedure and were advised that, while some risk was unavoidable, a key to a successful outcome was to ensure the administration of his prescribed Parkinson’s medication post-operatively.
On 5/1/19, Mr Woodhouse fell and suffered a cut to his elbow that required stitching.
On 16/1/19, Mr ████████ performed a total knee replacement at St Michael’s. The operation itself went well.
On 21/1/19, without Mr ████████ being advised, Mr Woodhouse was transferred to RCHT (Karenza ward) for post-operative delirium and related complaints.
Mr Woodhouse developed an infected left elbow. There was a delay in the administration of anti-biotics – possibly due to CRP levels not being checked – and Mr Woodhouse required a wash-out in theatre.
Mr Woodhouse’s knee became infected and also required a wash-out.
He deteriorated and died on 11/2/19.

i) The family complained they were unable to get staff on Karenza ward to listen to them. It was accepted in evidence that, at the time, there were staffing difficulties on the ward that have since been addressed.

ii) A lack of cleanliness with Mr Woodhouse being left in soiled bedding and clothes. It was not possible at inquest to come to a view that this was the cause of the infections in the knee and/or elbow.

iii) Potential delay in the administration of antibiotics. In evidence, Dr ████████ accepted that with the benefit of hindsight this was the case. While it was not causative of the death it was possible this had resulted in an avoidable wash-out in theatre;

iv) Delays or omissions of prescribed Parkinson’s medication. Matron ████████ had reviewed the nursing records. She accepted in evidence that there were ‘multiple’ occasions when medication was given late and three occasions when it was not given at all. She conceded nursing standards had fallen below what could reasonably be expected.
The inquest was told this is a national problem coming out of the difficulties caused where a patient needs time-specific medication that falls outside traditional ward times for the administration of medication.
I was also informed that a business case has been prepared for consideration by the Board for the appointment of a specialist Parkinson’s nurse and pharmacist. It was not known whether the case had been accepted and, if so, when it will be taken forward.