Pin
Get email alerts
Request correction
Investigation and inquest
On the 12th October 2018 I commenced an investigation into the death of John Andrew Mellor
Circumstances of the death
John Andrew Mellor suffered from diabetes mellitus, chronic kidney disease and deep vein thrombosis, which had previously caused cerebrovascular accidents and required warfarin therapy. He was under the care of his GP, as well as specialist teams, particularly the Department of Renal Medicine at Salford Royal Hospital.
On the 10th August 2018 he attended the Renal Medicine outpatient clinic, where he was commenced on Erythropoietin (EPO) treatment due to acute anaemia. Salford Royal Hospital sent a letter to Mr Mellor on the 10th August 2018, with a copy sent to his GP, asking him to arrange Full Blood Count tests with his practice nurse or district nurse around the 24th August 2018 and every two weeks thereafter. Mr Mellor made extensive efforts to have his blood tested, however his GP practice stated they did not have capacity to undertake the tests and the District Nursing Team indicated that as he was not house bound, they would not perform the tests. Mr Mellor was eventually able to have his blood taken and tested at the Royal Oldham Hospital on the 24th August.
On the 31st August 2018, a further letter was sent by Salford Royal Hospital to Mr Mellor, although this letter was not copied to his GP. The letter informed him that he was due to have a Full Blood Count, among other tests and that he should take the letter to his GP or come to the clinic in Salford if he had an appointment. The letter told Mr Mellor to mark the samples for them to be returned to the Renal Medicine Department.
Mr Mellor was not due to be seen by the clinic for some time. All attempts made by Mr Mellor or his representatives to have his blood tested by his GP, the District Nurses or Royal Oldham Hospital proved unsuccessful, with each agency indicating it was not their responsibility. Mr Mellor was constantly passed between agencies. There were insurmountable difficulties, for practical, financial and health reasons, with Mr Mellor attending Salford Royal Hospital from his home address to have his blood tested fortnightly. Due to the absence of blood tests, Mr Mellor was advised not to administer the EPO.
Mr Mellor continued to have his INR levels checked throughout August and September 2018, indicating normal INR levels. On the 27th September, Mr Mellor attended a clinic in Salford, his blood was tested and results the following day revealed a very low blood count requiring an urgent transfusion. Mr Mellor was contacted, but he collapsed at home on the morning of the 28th September and was taken to the Royal Oldham Hospital. Despite extensive treatment, his condition deteriorated and he died on the 3rd October 2018.
The Inquest established the cause of death as:
1a End Stage Renal Failure
1b Diabetic Neuropathy
2 Upper Gastrointestinal Bleed, Anti-Coagulation Therapy, Deep Vein Thrombosis.
The inquest could not establish whether the failure to administer the EPO caused or contributed to Mr Mellor’s death.
The Inquest heard evidence from the Next of Kin and General Practitioner, which detailed the unsuccessful steps that were taken to obtain a blood sample, as well as contemporaneous notes of the communication between agencies at the time. The GP has since sent a letter to the local Care commissioning Group, Dr Patterson, relating to his concerns regarding deficiencies in the care interface.
The Conclusion of the Inquest was:
Natural causes to which the known side effects of necessary anti-coagulation therapy more than minimally or trivially contributed.
Coroner’s concerns
That there appears to have been a systematic failure to ensure that blood tests are conducted, where required, for individuals under specialist, secondary care for renal failure. Individual patients, who may not be local to the specialist centre, will inevitably fail to have the appropriate assessments, care and treatment, in the absence of a clear line of responsibility.
The failure to establish a shared care arrangement, or at least to ensure that an organisation was identified in order to undertake blood sampling for drug monitoring, is insecure and unsafe.
It is also concerning that responses or updates to referrals, as well as requests for tests in the community, have not been communicated to primary care directly, with the sole reliance on a patient to pass vital documentation on to his primary healthcare provider.
Information checked against the published report and official responses