Harold Goulding
14 Jul 2016 · Coroner Nadia Persaud · London (East)
The coroner's concerns
1. breakdown of communication between anti-coagulation clinic, GP and care home
“The evidence revealed a breakdown of communication between the anti- coagulation clinic, the General Practitioner and the Care Home. The Care Home had registered Mr [name redacted] with a new General Practitioner but did not notify the anti-coagulation clinic of the details of the new General Practitioner. The community pharmacist therefore continued to provide reports to the old GP.”
2. failure to consider medication administration record
“The General Practitioner provided the lead in relation to the administration of medication at the care home. The General Practitioner did not however consider the Medication Administration Record held by the home.”
3. lack of information sharing when registering new residents with new GP
“It was further agreed that in order to reduce future risk, the Care Home staff should take the lead in ensuring that any other health agencies providing care to new residents are informed when the home registers new residents with a new General Practitioner, so that information can be correctly shared.”