Source · Prevention of Future Deaths
Maria Howell
Ref: 2022-0022
Date: 27 Jan 2022
Coroner: Michelle Brown
Area: Essex
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe care home lacked qualified nursing staff to reinsert a time-critical RIG tube for a resident with complex needs. Concerns were also raised about staff clinical judgment regarding critically ill patients who required urgent medical attention.
Date
27 Jan 2022
56-day deadline
24 Mar 2022 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The care home lacked qualified nursing staff to reinsert a time-critical RIG tube for a resident with complex needs. Concerns were also raised about staff clinical judgment regarding critically ill patients who required urgent medical attention.
View full coroner's concerns
That the Care Home had a resident with specific complex needs, and they had no qualified nursing staff to reinsert a RIG tube which is time critical. That they employ staff whose clinical judgement on someone who is critically ill does not necessitate urgent medical attention.
Report sections
Investigation and inquest
4 CIRCUMSTANCES OF THE DEATH
Maria Howell who died on the 28th September 2019 at Basildon University Trust Hospital, Nethermayne, Basildon, was resident in Cranham Court Nursing Home and she had a RIG tube in place. The nurse on duty noticed that the RIG tube had fallen out, but was not trained to reinsert, she delayed calling for an ambulance so the timings as to when this fell out was unknown. She was taken to Basildon A & E and at the hospital some hours later she had the PEG button reinserted and was discharged home. The same nurse was on shift that evening and Mrs Howells became unwell, around 7pm. No ambulance was called by the nurse until the day nurse came on duty, some 12 hours later. Mrs Howell was taken by ambulance where it was diagnosed that she had Peritonitis and sadly passed away on the 28th September 2019
Maria Howell who died on the 28th September 2019 at Basildon University Trust Hospital, Nethermayne, Basildon, was resident in Cranham Court Nursing Home and she had a RIG tube in place. The nurse on duty noticed that the RIG tube had fallen out, but was not trained to reinsert, she delayed calling for an ambulance so the timings as to when this fell out was unknown. She was taken to Basildon A & E and at the hospital some hours later she had the PEG button reinserted and was discharged home. The same nurse was on shift that evening and Mrs Howells became unwell, around 7pm. No ambulance was called by the nurse until the day nurse came on duty, some 12 hours later. Mrs Howell was taken by ambulance where it was diagnosed that she had Peritonitis and sadly passed away on the 28th September 2019
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Report details
- Reference
- 2022-0022
- Date of report
- 27 January 2022
- Coroner
- Michelle Brown
- Coroner area
- Essex
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 24 Mar 2022 (estimated from the report date).
Sent to
- Holmes Care Group Limited