On the 27/h February 2014 commenced an investigation into the death of Mary Catherine Bloom_ The investigation concluded at the end of the Inquest on the 30"h October 2015. The conclusion of the Inquest was a short form conclusion of natural causes_

Catherine Bloom suffered from dementia: There was a 12 month history of cognitive decline reduced oral intake. She was admitted to Queens Hospital on the 3r4 February 2014 with a history of 3 weeks of significantly reduced oral intake and rapid change in her left leg over 4 hours that morning: The initial impression was that Mrs Bloom was suffering from probable ischemia in the leg, hypovolemia and general decline_ She was admitted under the care of the vascular surgical team: The plan in place was for her to receive intravenous fluids, antibiotics and heparin: She was not considered to be a candidate for surgery. The heparin was not expected to reverse the thrombosis but to prevent further deterioration: loading dose of 500Ounits of heparin was administered at 17:40 and an infusion of 20,000 units put up at 18.30. Mrs Bloom's weight was not recorded prior to the administration of heparin or at all her admission. The infusion rate was not calculated on the basis of her weight; as it should have been: The Trust policy requires baseline bloods to be taken and then APTT ratios to be checked 6 hours Baseline bloods were not taken, as bloods were haemolysing in A & E also haemolysed when an attempt was made by the surgical registrar. There was no attempt to repeat bloods after hydration had commenced. There was no consultation with the consultant haematologist in view of Mrs Bloom's very low weight of 30 kilograms: The haematologist is likely to have advised a reduced loading dose and a reduced infusion rate. Mrs Bloom was admitted to the ward at 20.00 hours and was noted to have a reduced blood pressure at 21.50. The nurse caring for her also questioned the possibility of melena: A doctor attended the ward to review Mrs Bloom and considered that the drop in blood pressure was due to dehydration: Fluids that had been written up previously were not ongoing and therefore_he re-sited the cannula and advised that fluids be recommenced at a slightly Mary and during every They increased rate_ At around 23.45 the nurse caring for Bloom noted that her condition was deteriorating: She was noted to have passed away at 00.50 on the 4"h February 2014. CPR was not attempted as a DNAR order had been put into place by the consultant in charge of her care. There was no discussion with the next of kin to placing the DNAR order in her notes. The pathologist who carried out the post-mortem examination did not find any evidence of bleeding and did not consider that excessive administration of heparin had contributed to Mrs Bloom's death: The pathologist gave a cause of death 1a dementia and Il coronary artery atheroma; mitral valve disease and acute limb ischaemia