Doreen Willis · Prevention of Future Deaths report

On 16/06/2015 I commenced an investigation into the death of Doreen Willis, 80. The investigation concluded at the end of the inquest on 6 June 2017. The conclusion of the inquest was NARRATIVE The deceased had a history of strokes due to clotting. Her risk of stroke was approximately 9% per year. This risk was mitigated by taking the medication Rivaroxiban For a period of time she did not receive Rivaroxiban. The absence of Rivaroxiban may have contributed to her death. She died at Belle Vue Care Home, Paignton on 9 June 2015. Massive Cerebral Vascular Accident

Reporting as safeguarding issues (as discussed by next of kin originally). Lady was admitted to TBH on 17/05/15 with a stroke then transferred to Brixton Hospital on 22/05/15. On 03/06/15 she was discharged to Belle Vue for end of life care. Prior to that she had been at Primley Court Nursing since 02/04/15 having been discharged there from Braixham Hospital. Vaguely aware that at Primley Court she was not given her Rivaroxiban. Had been seen by her previous surgery and notes not yet with new surgery ████████ states cause of death is a) Stroke

At the conclusion of the Inquest I asked ████████ who presented evidence in connection with the Root Cause Analysis Report to summarise the key areas of learning identified. I am attaching her letter to my office of the 22 June 2017.

I would ask you please to have regard to those recommendations when your organisation carries out future inspections of care homes.

Would you kindly review the nature of CQC inspections in the light of ████████ key learning points.