James Edward Mansfield · Prevention of Future Deaths report

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.

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.

(1) Mr Mansfield had an xray and was discharged from Addenbrookes Hospital on 25 February. You have arranged that the hospital post discharge letters to your surgery. This was not 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.