Philip Ashton
PFD Report
Historic (No Identified Response)
Ref: 2018-0146
Coroner's Concerns (AI summary)
Medication errors occurred due to flawed procedures, staff were unprepared for emergencies, and vital medical history was inaccessible to ambulance crews.
View full coroner's concerns
_ (1) That warfarin was administered to the deceased in error and the home should review their medication procedures and put in place a robust system for the administration of anti coagulation medication (2) The staff were not able to deal with an emergency situation: (3) The ambulance staff were not given any information about the deceased as to his medical history or medication. The notes relating to the deceased should been available to them. aged applied the have
Sent To
- PJ Care
Response Status
Linked responses
0 of 1
56-Day Deadline
9 Jul 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 20th October 2017 commenced an investigation into the death of Philip David Ashton,
45. The investigation concluded at the end of the inquest on 23"d April 2018. The narrative conclusion of the inquest was: The deceased was administered warfarin in error on 13th, 14th, and 15th October 2017. On the morning of the 17th October 2017 he was found on the floor of his room at Mallard House, Milton Keynes, bleeding from his arteriovenous graft in his left thigh. There was no attempt to stop the bleeding until the paramedics arrived on the scene and tourniquet: The delay resulted in a missed opportunity to prevent the hypovolaemic shock and the medication error contributed to the serious degree of bleeding: He was stabilised and transferred to Milton Keynes Hospital where he died at 12.37 pm.
45. The investigation concluded at the end of the inquest on 23"d April 2018. The narrative conclusion of the inquest was: The deceased was administered warfarin in error on 13th, 14th, and 15th October 2017. On the morning of the 17th October 2017 he was found on the floor of his room at Mallard House, Milton Keynes, bleeding from his arteriovenous graft in his left thigh. There was no attempt to stop the bleeding until the paramedics arrived on the scene and tourniquet: The delay resulted in a missed opportunity to prevent the hypovolaemic shock and the medication error contributed to the serious degree of bleeding: He was stabilised and transferred to Milton Keynes Hospital where he died at 12.37 pm.
Circumstances of the Death
The deceased was a resident of Mallard House Milton Keynes_ He attended hospital three times a week for dialysis. He had an arteriovenous graft on his left thigh. On the 13"h , and 15th October 2017 the deceased was administered warfarin in error. He was found in his room on the 17h October 2017 bleeding from his graft. The ambulance attended and were surprised that no attempt had been made by the staff to resuscitate or stop the bleeding_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.