Mr Harold Goulding · Prevention of Future Deaths report

On the 13th November 2015 I opened an investigation into the death of Mr Harold Goulding. The investigation concluded at the end of the Inquest on the 13th July 2016. The conclusion of the Inquest was a narrative conclusion.

Mr Harold Goulding suffered 2 falls in his care home on the 5th and 6th November 2015. He was admitted to hospital on the 6th November 2015 where end stage heart failure and an acute on chronic subdural haematoma were diagnosed. On the 10th November 2015 he suffered a seizure from which he did not recover. The most likely cause of the fatal seizure was the trauma of the falls and consequent head injury.

Mr Goulding suffered a fall at the Alexander Court Care Centre in the early hours of the 5th November 2015. He was seen by a GP on 5 November 2015 who checked him for fractures. The GP was not aware that Mr Goulding was on warfarin therapy and there was no record of any assessment for a head injury. The GP had not received reports from the anti-coagulation clinic and he did not check the Care Home’s medication administration record.
He Goulding suffered a second fall on the 6th November 2015. He was taken to hospital following the second fall. The main clinical concerns at this time were of shortness of breath, swollen neck and swollen arms/legs. The initial impression upon attendance to hospital was of end stage heart failure. A CT scan carried out on the 7th November 2015 confirmed an acute on chronic subdural haematoma. Mr Goulding remained in hospital and was stable until the 8th November 2015 when it was noted that he was suffering from swallowing difficulties. His family also noted an increase in his level of confusion at this time. On the morning of the 10th November 2015 he suffered from a seizure. Despite anti-epileptic medication and management of his airway, he suffered a cardiac arrest. Life was pronounced extinct at 09:46 on the 10th November 2015. At the Inquest the cause of death was found to be 1a cardiac arrest 1b seizure 1c fall, head injury and subdural haematoma (on warfarin therapy). 2 congestive cardiac failure; type 2 diabetes and hypercholesterolemia.

1. The evidence revealed a breakdown of communication between the anti-coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr Goulding with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP.

2. The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home.

The staff providing evidence from the care home agreed that it would reduce risk in the future, if a system is in place to ensure that the General Practitioner attending for new resident reviews, considers and approves the medication set out within the Medication Administration Record. This would not only provide assurance to the Care Home staff in relation to medication that they are administering, but would also ensure that GPs are fully aware of the medication that residents are currently receiving.

It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared.