David Michael Potts · Prevention of Future Deaths report

On 27 August 2019 I commenced an investigation into the death of David Michael Potts aged 82 years. The investigation concluded at the end of the inquest on 19 November 2019. The conclusion of the inquest was a narrative detailing Mr Potts’ fall at home and development of an Acute Subdural Haematoma. He was on Apixaban. It was recommended that he be given Beriplex to reverse the effects of the Apixaban.
Cause of Death 1a) Hospital Acquired Pneumonia, 2 Right Subdural Haematoma.

Mr Potts fell at home hitting his head. He was prescribed apixaban. When admitted it was discovered that he had an acute subdural haematoma. Specialist Neurology advice was sought and the treating doctor prescribed Beriplex to reverse the effects of the Apixaban. This was ready the same day and available from the pharmacy. No-one followed this up and at one point it was thought it hadn't been given because he was having an x-ray so off the ward. In fact, he did not leave the ward for any radiology that day, but it appears there was no documentation about his whereabouts. In any event the Beriplex was not given for some time and his bleed extended. He stabilised enough to be transferred to a local unit for possible rehabilitation. He declined after transfer and died 7 days later.

(1) That the prescription of Beriplex was not given in a timely manner.

(2) That no-one checked that it had been given despite an extension of the bleed.
(3) That no-one seemed to know why it was not given as ordered or where Mr Potts was on the day in question.