Source · Prevention of Future Deaths

Michael Nye

Ref: 2024-0082 Coroner: Alison McCormick Area: Berkshire Responses identified: 1 / 2 View PDF

Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on sepsis recognition and escalation policies.

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Multiple systemic failures included delays in night-time diagnostics and abnormal result notification, poor record-keeping, and inadequate training on sepsis recognition and escalation policies.

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a. Delays in blood tests being completed at night at the Royal Berkshire Hospital, and notification to clinicians on the Electronic Patient Record of abnormal results which are being reviewed.;
b. The burdensome and time consuming out of hours system for clinicians requesting CT scans from an external provider;
c. The lack of contemporaneous record keeping in the Emergency Department;
d. The lack of a specific night time Internal Escalation Policy. A number of the general Internal Escalation Policy measures are not effective at night;
e. The need for training of all Intensive Care Unit clinicians at all levels, both existing Intensive Care Unit clinicians and new joiners, in the policy that a "just to let you know" call should result in an Intensive Care review of the patient;
f. The need for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate.

Responses

1 respondent

Royal Berkshire NHS Foundation Trust NHS / Health Body

PDF

Action Taken

The Trust's Lead Nurse for Sepsis has already delivered focused training sessions in the ED and held discussions at Critical Care Outreach Service and ICU governance meetings to improve sepsis identification. (AI summary)

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r1:k1 Royal Berkshire NHS Foundation Trust
f. T he ned for training and education of all clinicians on atypical presentation of sepsis and the need for a high index of suspicion for sepsis, particularly in the presence of a high lactate The trust's Lead Nurse for Sepsis has delivered focused training in the areas with high prevalence of Sepsis - with teaching sessions in ED as well as discussion at Critical care outreach service (CCORS) and ICU governance meetings. Please see Appendix Bii . I trust this has provided some assurance in some of the changes that are being implemented in ED in order to improve patient safety. Please do not hesitate to contact me should you need any further information.

Report sections

Investigation and inquest

On 18 November 2022 I commenced an investigation into the death of Michael James NYE aged 48. The investigation concluded at the end of the inquest on 07 February 2024. The conclusion of the inquest was that: On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye’s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye’s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022. On the balance of probability Mr Nye’s death was more than minimally contributed to by: (i) over-crowding in the Emergency Department, lack of a resus bed and pressure on clinical resources; (ii) delay in considering a differential diagnosis of sepsis from skin and soft tissue infection; (iii) delay in obtaining blood test results; (iv) delay in organising and undertaking CT scanning; (v) delay in prescribing antibiotics to target sepsis from skin and soft tissue infection; (vi) delay in escalating his case to the Intensive Care Team.

Circumstances of the death

On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye’s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye’s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022.

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Report details

Reference: 2024-0082
Coroner: Alison McCormick
Coroner area: Berkshire

Responses identified

Responses identified 1 of 2

All listed responses identified

Sent to

Berkshire and Surrey Pathology Services

Royal Berkshire Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.