Marie Quinn, otherwise known as Marie Pearson Quinn · Prevention of Future Deaths report

On the 20th July 2015 I commenced an investigation into the death of Marie Quinn, otherwise known as Marie Pearson Quinn, born on the 25th October 1938.

The investigation concluded at the end of the inquest on the 23rd October 2015.

The Medical Cause of Death was:

1a Pulmonary Embolus
1b Deep Venous Thrombosis
1c Fractured Right Neck of Femur
2 Sub-optimal Deep Venous Thrombosis Prophylaxis

The conclusion of the inquest was that Marie Quinn, also known as Marie Pearson Quinn, died as a consequence of injuries sustained in an accidental fall and a recognised complication of the subsequent surgical treatment of those injuries, in circumstances where the appropriate, and prescribed prophylaxis treatment was not given.

On the 20th May 2015 Mrs Quinn fell in the kitchen at her home address at ████████ sustaining a fracture to her right neck of femur. She was admitted to the Royal Bolton Hospital, Bolton and underwent surgery to repair the fracture on the 21st May 2015. She was discharged to Richmond House Nursing Home, Mitchell Street, Leigh for

rehabilitative care on the 29th May 2015 and was later discharged to her home address on the 22nd June 2015.

On the 13th July 2015 Mrs Quinn became unwell and was transferred to the Royal Bolton Hospital, where her condition deteriorated and she died.

1. During the inquest evidence was heard that:

i. The policy adopted by the Royal Bolton Hospital, Bolton for any person undergoing surgery to repair a fractured neck of femur is to administer prophylaxis treatment following that surgery to reduce the risk of developing a deep venous thrombosis. The treatment that should be given is prophylaxis medication, such as Dalteparin, a low molecular weight heparin, which should commence the day of the surgery and continue for a 4 week period following surgery, and mechanical prophylaxis whereby Flowtron boots are worn by the patient continuously for a specified period of time following surgery.

ii. Following Mrs Quinn’s surgery to repair her fractured neck of femur she was not given Dalteparin until the 22nd May 2015, the day after her surgery. She was then prescribed Dalteparin until the 18th June 2015, which would have been 4 weeks after the operation. Mrs Quinn was also not given Flowtron boots to wear after her surgery.

iii. Upon Mrs Quinn’s discharge to Richmond House she continued to be prescribed Dalteparin, which is administered by way of an injection, and was discharged with sufficient injections to complete the course on the 18th June 2015. The hospital notes which accompanied her discharge detailing instructions to the Nursing Home regarding her medication however, indicated that Dalteparin should be administered until the 11th June 2015. As a result Dalteparin was stopped on the 11th June 2015.

iv. The Deputy Manager of Richmond House gave evidence that there were a number of injections left over on the 11th June 2015 which had been sent from hospital, but no action was taken in relation to the excess medication. He confirmed that the Home did not contact the Hospital to enquire why there were extra doses of the medication, and stated that in his experience there have been other occasions where residents at the Home had extra doses of medication left after the course prescribed had been completed.

v. Evidence given by the Consultant Histopathologist at the inquest confirmed that the sub-optimal deep venous thrombosis prophylaxis was a contributory factor in Mrs Quinn’s death.

vi. Evidence was given that there had been a review undertaken by the Royal Bolton Hospital following Mrs Quinn’s death, which identified that Dalteparin should have been given on the 21st May 2015 and should have continued until the 18th June 2015. Their review found that the notes provided to the Home had been inaccurate. As a result of that review action has been taken to prevent this occurring again.

2. I have concerns with regard to the following:

i. The management of the medication for the residents at Richmond House Nursing Home.

ii. Evidence was given at the Inquest that there are occasions where Richmond House Nursing Home are left with excess medication that is prescribed to, or directed to be taken by, a resident in their care. This medication should be accounted for and should therefore be queried as residents may not be given medication in circumstances where they should be. I therefore request that Richmond House Nursing Home, which is governed by HC-One Limited, review their policies and procedures regarding the management of the medication prescribed to their residents.