Mr Terence Hawkins · Prevention of Future Deaths report

On the 31st May 2016 I commenced an investigation into the death of Mr Terence Hawkins. The investigation concluded at the end of the Inquest on the 16th December 2016. The conclusion of the Inquest was that Mr Hawkins died from natural causes.

Mr Hawkins was an 88 year old gentleman. He had been admitted to St. Catherine’s Residential Care Home in 2010 and registered with the Lime Tree surgery in June 2010. He had background medical history of dementia, alcohol abuse, osteoporosis and recurrent falls. He had also developed swallowing difficulties. He was cared for at St. Catherine’s Residential Care Home under a Deprivation of Liberty Safeguarding authorisation. In March 2016 the care home requested a GP visit due to increased frailty and loss of weight. A routine GP visit should have taken place, but did not. During the early hours of the 12th May 2016, Mr Hawkins was found to be vomiting in his bed. The care assistant was in the course of changing his clothing and bedding when he noted Mr Hawkins had become unresponsive. The London Ambulance Service were called and CPR was commenced. It was later discovered that a DNAR order had been in place. Upon arrival of the paramedics it was clear that Mr Hawkins was deceased and life was pronounced extinct at 05:12 on the 12th May 2016. A forensic post-mortem was carried out which confirmed a cause of death of 1a: Congestive heart failure, 1b: Ischaemic heart disease and 2: Alzheimer’s disease.

1. There was no system in place for the regular medical monitoring of residents with the Care Home. Mr Hawkins had not been seen by a GP for many months. The Care Home Manager confirmed that it could be difficult for medical assessments to be arranged for residents within the home who are unable to attend the surgery.

2. Both the GP and Care Home Manager indicated that regular GP reviews (perhaps monthly) within the home, by the GP practice would improve the care provided to residents.