Harold Mullins · Prevention of Future Deaths report

On the 18th January I commenced an investigation into the death of Harold Mullins aged 92. The investigation concluded at the end of an inquest on the 18th April 2017. The conclusion of the inquest was that of "natural causes".

The deceased was admitted to the Royal Glamorgan Hospital on the 3rd January having sustained a fall or collapsed at home address. No detail was known as to what may have caused that. On admission to hospital he was found to have a fracture to the left neck of femur. He had a raised INR level and an Acute Kidney Injury and therefore surgery was delayed until the 5th January. On the afternoon of that day he underwent surgical repair of the fracture to his hip. After surgery his standard observations (NEWS scores) were noted to be raised. In the early parts of the evening they continued to rise and assistance was sought by the nursing staff from one of the clinical team treating Mr Mullins. The Doctor indicated that “they were not concerned” as Mr Mullins had undergone surgery and did not examine him. The matter was then further escalated when his blood pressure fell further and no clinician was available to examine him. The initial contact with the treating clinician appears to have been at 2010 hours and the matter escalated again at 2145. On that occasion advice was given for fluids to be administered but again the treating clinician did not see Mr Mullins. By the time the clinician did see Mr Mullins he had suffered a cardiac arrest and despite efforts could not be resuscitated.

(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general.

(2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion.

There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery.