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Investigation and inquest
On 22nd September 2016 I commenced an investigation into the death of Mr William Frederick Wilkes, aged 80. The investigation concluded at the end of the inquest on 10th May 2017. The conclusion of the inquest was that he died as the result of an accident.
Circumstances of the death
The deceased was admitted to Milton Keynes University Hospital on 4th July 2016 following a fall at Neath House Residential Home.
By 19th July 2016 the deceased was ready for discharge from the hospital. Neath House indicated that they were unable to meet his needs unless a carer could be provided to stay with him 24 hours a day.
A Continuing Healthcare Checklist was completed on 26th July 2016. The Decision Support Tool was completed and an assessment by a Continuing Healthcare Nurse Assessor was completed on 8th August 2016.
The report and confirmation of funding was completed on 17 August 2016.
The Continuing Healthcare Team was unable to find a suitable placement for the deceased.
The file was misplaced in the non-eligible tray that added to the delay from 19th August 2016 to the 30th August 2016.
The failure to discharge the deceased resulted in him being cared for on Ward 18 which was inappropriate to meet his needs.
There was a failure in communication between the hospital, the CCG and the family.
The deceased was placed on one-to-one enhanced care but it was not always provided.
The deceased suffered a further fall on 18th September 2016 and fractured his hip.
The deceased died on 22nd September 2016.
Coroner’s concerns
During the course of the inquest it became apparent that the protocol and procedure for discharge of someone from hospital was cumbersome and time-consuming. The result in this case was that, although the deceased was ready for discharge to a nursing home on the 19th July, he was not able to be transferred to a more appropriate care home prior to his death on 22nd September.
I also heard from the patient discharge lead from the hospital that the system was in urgent need of review.
Concerns
1. That a system needs to be put in place locally so that the procedures for effecting discharge can be implemented within days rather than weeks.
2. That a local protocol should be considered by both the Hospital Trust and the Clinical Commissioning Group for Milton Keynes.
Information checked against the published report and official responses