Mr Ronald Francis Bonfield · Prevention of Future Deaths report

On the 3rd October 2014, I commenced an investigation into the death of Mr Ronald Francis Bonfield. The investigation concluded at the end of the inquest on the 9th September 2015. The conclusion of the inquest was - 'The deceased took Warfarin as an anti-coagulant. On the 29th September 2014 he sustained a head injury whilst at home when a chair he sat on toppled backwards. He was diagnosed with a subdural haematoma. He had sustained this injury at a time when he was over anti-coagulated. His INR levels were not being monitored as required. His untreatable condition deteriorated and he passed away at Prince Charles Hospital on the 2nd October 2014 at 10pm'.

Whilst at home on 29th September 2014, the deceased sustained a head injury when he struck his head on the handle of a kitchen door. On 1st October 2014 he was admitted to Prince Charles Hospital. A head injury was diagnosed, but he was not for active surgical intervention. He deteriorated and died at Prince Charles Hospital on 2nd October 2014.

(1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield’s death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient’s INR testing) is not uniform and/or implemented across all of the Health Boards Level 4 Accredited GP practices.

(2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned.

(3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield’s, where delegated INR testing has not been done leading to unmonitored over anti-coagulation