UK Inquiry Tracker

Harold Mullins

PFD Report Historic (No Identified Response) Ref: 2017-0127

Date of Report 20 April 2017

Coroner Andrew Barkley

Coroner Area South Wales Central

Response Deadline est. 28 July 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

The surgical team was unaware of the patient's thrombosis history. Deteriorating NEWS scores did not trigger timely clinician review, highlighting a failure in information sharing and effective care escalation.

View full coroner's concerns

In the circumstances it is my statutory to report to you: as follows The day the they the duty

A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of vein thrombosis when undertaking the surgery and caring for in general: (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion, There appears to be a difiiculty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was to be expected given that he had undergone surgery:

Sent To

Cwm Taf Health Board

Response Status

Linked responses 0 of 1

56-Day Deadline 28 Jul 2017

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 the 18"h January commenced an investigation into the death of Harold Mullins aged
92. The investigation concluded at the end of an inquest on the 18" April 2017. conclusion of the inquest was that of "natural causes

Circumstances of the Death

The deceased was admitted to the Royal Glamorgan Hospital on the 3" January having sustained a fall or collapse at his home address No detaii was known as to what may have caused that: On admission to hospital he was found to have a fracture to the left neck of femur; He had a raised INR level and an Acute Kidney Injury and therefore' surgery was delayed until the 5lh January. On the afternoon of that he underwent surgical repair of the fracture to his hip. After surgery his standard observations (NEWS scores) were noted to be raised. In early parts of the evening continued to rise and assistance was sought by the nursing staff from one of clinical team treating Mr Mullins_ The Doctor indicated that "they were not concerned" as Mr Mullins had undergone surgery and did not examine him. The matter was then further escalated when his blood pressure fell further and no clinician was available to examine him The initial contact with the treating clinician appears to have been at 2010 hours and the matter escalated again at 2145. On that occasion advice was given for fluids to be administered but again the treating clinician did not see Mr Mullins. By the time the clinician did see Mr Mullins he had suffered a cardiac arrest ad despite efforts could not be resuscitated.

Action Should Be Taken

In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power to take such action.