On the 20th June 2019 commenced an investigation into the death of Doris Laura Clark: The investigation concluded at the end of the Inquest on the 18th December 2019. conclusion of the Inquest was the short form conclusion of "accident"

Mrs Clarke fell in her home address on the 3rd November 2018 She remained on the floor for around 6 hours before paramedics were called. Paramedics attended and suspected that she had suffered a fractured neck of femur, The paramedics administered 5 mls (10 milligrams) of Oramorph at 15.40. A further 5 mls milligrams) was administered at 15.50. Despite this administration of pain relief, Mrs Clark reported severe pain on arrival to hospital. She was seen by an A & E consultant who prescribed a further 10 milligrams Of morphine to be administered intravenously This further dose of morphine was administered at 17.58_ It was not titrated, but was administered as a IV push. Following this administration; Mrs Clark was not monitored in accordance with Trust policy. Mrs Clark suffered a large vomit whilst lying flat At around 19.00 hours Mrs Clark was noted to be unwell with reduced oxygen saturation and reduced conscious levels Pulmonary embolism , chest infection (possible aspiration) and or opiate toxicity were considered as potential causes_ She received treatment with oxygen IV fluids and antibiotics_ Naloxone was also given to reverse the effect of opiate medication. pulmonary embolism was ruled out: Mrs Clark continued to receive treatment in the form of fluids, antibiotics and oxygen. Sadly however she passed away at Queens Hospital on the 11th November 2018. It is likely that the fall and long lielimmobility caused by the fractured femur and the administration of 30 milligrams of morphine over a 2 hour 20 minute period, contributed to her death.

In my opinion action should be taken to power to take such action. prevent future deaths and believe you have the