Ronald Bonfield
PFD Report
Unknown
No published response · Over 2 years old
Response Status
Responses
0
56-Day Deadline
6 Nov 2015
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
The matters of concern as follows: (1) The practices and procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield's death (with regard to monitoring the compliance of the Health Boards District Nurse Teams following delegation to undertake a patient's INR testing) is not uniform andlor implemented across all of the Health Boards Level 4 Accredited GP practices (2) The practices and procedures implemented by Practice 1 , Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitoredlunactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned (3) Until such action is taken there remains a risk that a future death(s) could occur in similar circumstances to Mr Bonfield's, where delegated INR testing has not been done leading_to un-monitored over anti-coagulation
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action in the area of: Ensuring that all level 4 accredited GP practices across the Cwm Taf Health Board area follow the (monitoring) practices & procedures implemented by the Practice 1, Keir Hardie Health Park, GP Surgery following Mr Bonfield's death
Report Sections
Investigation and Inquest
On the 3" October 2014, commenced an investigation into the death of Mr Ronald Francis Bonfield. The investigation concluded at the end of the inquest on the g"h September 2015. The conclusion of the inquest was 'The deceased took Warfarin as an anti-coagulant: On the 29"h September 2014 he sustained a head injury whilst at home when a chair he sat on toppled backwards: He was diagnosed with a subdural haematoma: He had sustained this injury at a time when he was over anti-coagulated: His INR levels were not being monitored as required: His untreatable condition deteriorated and he passed away at Prince Charles Hospital on the 2nd October 2014 at 1Opm'_
Circumstances of the Death
Whilst at home on 29th September 2014, the deceased sustained a head injury when he struck his head on the handle of a kitchen door On 1st October 2014 he was admitted to Prince Charles Hospital. A head injury was diagnosed, but he was not for active surgical intervention He deteriorated and died at Prince Charles Hospital on 2rd October 2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.