Source · Prevention of Future Deaths
Gillian McKinlay
Ref: 2021-0040
Date: 12 Feb 2021
Coroner: Dr James Adeley
Area: Lancashire & Blackburn with Darwen
0 responses identified · 2 indexed addressees
View PDF
AI-generated concerns summaryConcerns included a lack of clear clinical responsibility for long-stay A&E patients, failure to conduct mandated clinical reviews based on EWS scores, and a lack of escalation by nursing staff. The Trust's own investigation was also deemed inadequate.
Date
12 Feb 2021
56-day deadline
9 Apr 2021 est.
estimated from the report date
Responses identified
0 of 2
Coroner's concerns
Concerns included a lack of clear clinical responsibility for long-stay A&E patients, failure to conduct mandated clinical reviews based on EWS scores, and a lack of escalation by nursing staff. The Trust's own investigation was also deemed inadequate.
View full coroner's concerns
1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the other clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB Tel 01772 536536 | Fax 01772 530752 be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the other clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB Tel 01772 536536 | Fax 01772 530752 be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
Report sections
Investigation and inquest
4 CIRCUMSTANCES OF THE DEATH Mrs Gillian McKinlay, 68 years of age, was admitted to the Accident & Emergency Department of Royal Blackburn Hospital on 23 April 2018. The provisional diagnosis was of small bowel obstruction and both the A & E and Surgical Registrars requested siting of a nasogastric tube to decompress the bowel. The NG tube was not sited prior to Mrs McKinley's death four hours later, which in the Coroner's view, contributed to the death. Despite Early Warning Score indications that there should have been a significant review of Mrs McKinlay's condition in the 2 ½ hours before she arrested, there is no evidence that any such review took place.
A copy of the summing up is attached to this document for further information.
A copy of the summing up is attached to this document for further information.
Copies sent to
Care Quality Commission
Similar PFD reports
Report details
- Reference
- 2021-0040
- Date of report
- 12 February 2021
- Coroner
- Dr James Adeley
- Coroner area
- Lancashire & Blackburn with Darwen
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: 9 Apr 2021 (estimated from the report date).
Sent to
- Care Quality Commission
- East Lancashire Hospitals NHS Trust