George Boulton · Prevention of Future Deaths report

On 17 February 2015 I commenced an investigation into the death of George Boulton.

At inquest the determinations were that Mr Boulton had an intracerebral bleed at home on 12 February 2015; a spontaneous event. There was a delay in arranging this transfer to hospital during which time he erroneously received an injection of dalteparin... this action was material in the bleed continuing and he died on 14 February 2015 in Leicester Royal Infirmary from the consequences of this.

Cause of death
1a Left intracerebral haemorrhage

Mr Boulton was being cared for at home when he started to display symptoms of unsteadiness and difficulty in walking. The GP attended to request, and diagnosed probable stroke, and attempted to get the patient admitted to the local stroke team via bed bureau. There were no beds immediately available.

There was a delay in the ambulance arriving and therefore in admission as the request was not listed as an emergency, notwithstanding the diagnosis. In this case, during that time delay, the District Nurse attended for a routine daily appointment to administer dalteparin, an anticoagulant medication, and no communication had been made between the GP and community services to ensure this was not given, pending further investigations.

On admission to hospital, haemorrhagic stroke was confirmed by scan. It was not possible to adequately reverse the effects of dalteparin, and this materially contributed to the ongoing bleed.

1. It was recognised by all witnesses to the inquest that response to potential stroke symptoms should be on an emergency basis, in accordance with "FAST" criteria ie a timely response. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer.

2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission, and not be dependent on a bed, as early scanning was essential for proper diagnosis.

3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time, rather than the actual allocated 2 hour response time.

4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse; while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options.