Lottie Reid · Prevention of Future Deaths report

On 2 February 2015 I commenced an investigation into the death of Lottie Reid, aged 95 years. The investigation concluded at the end of the inquest on 23 June 2015. The conclusion of the inquest was that the deceased died from bleeding duodenal ulcers on a background of other significant natural disease. Her death was probably accelerated by a short time due to the bleeding being exacerbated by a recognised complication of anticoagulant drug therapy.

The deceased was 95 years of age with a background of atrial fibrillation, hypertension, congestive heart failure, hypertension, chronic kidney disease and hypothyroidism. She had been hospitalised in December 2014 following a fall and discharged for a second time to Perry Trees Intermediate care centre on the 7th January 2015. Her medication included enoxaparin and aspirin. She became more frail in the weeks prior to her death. On the 29th January 2015 she was readmitted to Good Hope Hospital, Rectory Road Sutton Coldfield with haematemesis and melaena. She deteriorated quickly and died at 12 o'clock on the 29th January 2015. Post mortem examination found significant natural disease including previously undiagnosed duodenal ulcers and cirrhosis of the liver.

(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription.
(2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends