Carol Ann Harvey · Prevention of Future Deaths report

On 12/04/2016 I commenced an investigation into the death of Carol Ann Harvey, (DOB 6.4.42, DOD 9.4.16). The investigation concluded at the end of the inquest on the 7th of March 2017 The conclusion of the inquest was by way of a Narrative Conclusion as set out in paragraph 4 below

Carol Ann Harvey was a seventy year old lady who had been receiving medical treatment at the Wrexham Maelor Hospital. By the 6th of April 2016 plans were being made for her discharge home with care and support being provided to her by her family, carers and district nurses.
On the 6th of April 2016 her INR was higher than was clinically ideal and this was being addressed by a reduction in her dosage.
At around 4.15pm on the 7th of April 2016, following a delay arising from some confusion relating to a Tissue Viability Review, confirmation was received that Carol was to be discharged and a telephone call was made to the generic health care team to advise them of this so that the care plan could commence. A message was left on an answerphone to this effect but no confirmation was obtained that these instructions had been received.
The answerphone was not checked until the following morning, notwithstanding that staff had returned to the office briefly around 7.00pm that evening.
No carers attended Carol Harvey during the evening of the 7th of April and it is probable that in the course of that evening and overnight she was in considerable pain as a result of a calf haematoma and consequently took an accidental overdose of painkillers.
At around 7.40am on the 8th of April she was found, drowsy and vomiting and she had suffered a large loss of blood which necessitated her readmission to hospital.
Despite appropriate treatment for her condition she continued to decline and passed away at the Maelor Hospital in the early hours of the 9th of April 2016 due to a combination of the effects of the paracetamol overdose and a pre-existing cardiac condition.

(a) That although a referral had been made to the District Nurse Team, there is no procedure in place to ensure that such a referral has been both received and actioned.

(b) The Action Plan which has been produced by the Health Board following an investigation into this death indicates that a Standard Operating Procedure for the safe discharge of patients from the Acute Hospital environment is being developed, however it was not possible to provide a completion and implementation date for this, notwithstanding that the death was eleven months ago. I am concerned that delays in undertaking work of this kind could place existing patients at risk.