Source · Prevention of Future Deaths

Philip Hawkins

Ref: 2023-0248 Date: 18 Jul 2023 Coroner: David Pojur Area: North Wales East and Central Responses identified: 0 / 2 View PDF

Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.

Date 18 Jul 2023
56-day deadline 12 Sep 2023 est.
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Significant delays in hospital admission and bed allocation, coupled with inadequate staffing, resulted in poor personal care, missed observations, and incomplete documentation for a vulnerable patient.
View full coroner's concerns
Entry into Hospital and Delay to bed allocation
1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED).
2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day.
3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23. Care Concerns in the ED
4. On 18.03.2 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas.
5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians.

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN |
6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician.
7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23.
8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him. Staffing
9. There were insufficient nursing and clinical staff to attend to the numbers of patients as outstanding nursing shifts went unfulfilled on the nursing rota.
10. Due to the presenting circumstances, staff were unable to fulfil their role in caring for Mr Hawkins.

11. Specifically, I am concerned as to the wait and delay Mr Hawkins had to endure to enter hospital and the same in respect of being provided with a bed; the inability of staff to tend to him; the lack of available staff and the lack of written record of assessment and treatment.

Report sections

Investigation and inquest
On 29.03.23 an investigation was commenced into the death of Philip Hawkins (DOB 09.07.1925) who died on 23.03.23. The investigation concluded at the end of the inquest on 18.07.23. The conclusion of the inquest was Accident.
Circumstances of the death
The circumstances of the death are as follows :- On 18.3.23 Mr Hawkins, aged 97, suffered a fall at home and was transferred by ambulance to hospital where he subsequently died.

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Report details

Reference
2023-0248
Date of report
18 July 2023
Coroner
David Pojur
Coroner area
North Wales East and Central

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Sep 2023 (estimated).

Sent to

Betsi Cadwaladr University Health Board
Welsh Ambulance Service Trust

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