1. During the inquest evidence was heard that: 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 deep venous thrombosis: The treatment that should be given is prophylaxis medication, such as Dalteparin, a low molecular weight heparin, which should commence day of the surgery and continue for week period following surgery, and mechanical prophylaxis whereby Flowtron boots are worn by patient continuously for specified period of time following surgery: Following Mrs Quinn's surgery to repair her fractured neck of femur she was not given Dalteparin until the 22nd 2015, the day after her surgery. She was then prescribed Dalteparin until the 18t June 2015, which would have been weeks after the operation: 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 o the 18t 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 11t June 2015. As a result Dalteparin was stopped on the 11m June 2015. iv The Deputy Manager of Richmond House gave evidence that there were number of injections left over on the 11t June 2015 which had been sent from the 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, ad 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 the the May Mrs had been completed: Evidence given by the Consultant Histopathologist at the inquest confirmed that the sub-optimal deep venous thrombosis prophylaxis was a contributory factor in 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 2015 and should have continued until the 18h 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: The management of the medication for the residents at Richmond House Nursing Home: Evidence was given at the Inquest that there are occasions where Richmond House Home are left with excess medication than is prescribed to, or directed to be taken bY, resident in their care: This medication should be accounted for and should therefore be queried as residents may not be 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;