Stanley Charles Dodson · Prevention of Future Deaths report

On 9/10/12 I opened an inquest into the death of Stanley Charles Dodson who, at the date of his deaths was aged 84 years. The inquest was resumed and concluded on 7th November 2013.
I found that the cause of death to be: -
1(a) Left Ventricular Failure
1(b) Hypertensive Heart Disease
I concluded with a narrative verdict.

On 1/10/12, Stanley Charles Dodson was found to have died at his home address at 2 Wallis Mews, Guildford Road, Leatherhead, Surrey. Prior to his death he had been prescribed warfarin for a thrombus and methotrexate for his Dermatomyositis, which were withdrawn by his doctor, given his failing short-term memory and confusion. Mr Dodson had a Mole Valley Community Alarm fitted and at approximately 10pm 30/9/12 he telephoned the operative to ask for a doctor to provide him with medication. The operative then contacted Harmoni to request the attendance of an on call doctor. The doctor responded by telephoning Mr Dodson 3 times but without response and he left a message on his answer phone to ask Mr Dodson to contact him or emergency services if necessary. Mr Dodson was found to have died the next day.

Although the Doctor made several attempts to directly contact Mr Dodson and left a telephone message for him, these difficulties were not reported back to the operative to enable consideration of further action to contact him.

I would be grateful if you could consider the appropriateness of extending your existing protocols to requirements that locum doctors should inform the operatives in the event of the non response of patients.