George Marks · Prevention of Future Deaths report

On the 20th of March 2014 I commenced an investigation into the death of George Marks, Aged 93. The investigation concluded at the end of the inquest on the 5th of November 2014. The conclusion of the inquest was natural causes contributed to by neglect.

Mr Marks was admitted in A&E Dept on the 14th of February 2014 with confusion, immobility and a chest infection. He was prescribed anticoagulant medication as a precaution given his age and immobility.

The diagnosis of DVT was confirmed on the 24th of February when scans showed he had a DVT in the leg and right sided thrombus in the pulmonary artery. On the 27th of February a decision was made to change the anticoagulant medication to Rivaroxaban - administered orally.

On the 27th of February Mr Marks was cared for by the first of a succession of agency nurses from the Mayday Healthcare PLC. From the evening of the 28th of February until the 4th of March, when a Doctor finally noticed, Mr Marks had failed to be given his medication and in particular the Rivaroxaban which was located in a ‘pod’ beside his bed.

Mr Marks declined and died on the 6th of March 2014. A Consultant Haematologist at the Inquest said that it was unlikely that a new embolism would have formed had Mr Marks been administered Rivaroxaban and further, that there was a very high probability that the new embolism caused or contributed to his death.

1) Agency staff failed to have an understanding of the basic policies and procedures in place when administering medication and / or where a patient refused to take such medication.
2) Agency Staff failed to have an understanding of the Drug Prescription Chart and / or failed to make any record, or any adequate record in the said chart
3) Agency Staff failed to have an understanding of the need to make a record and or any adequate record in the patients nursing notes,
4) Agency Staff failed to adopt the correct “Hand Over” procedure.