Source · Prevention of Future Deaths

Paul Reynolds

Ref: 2020-0178 Date: 21 Sep 2020 Coroner: Ian Arrow Area: Plymouth, Torbay and South Devon Responses identified: 1 / 1 View PDF

Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.

Date 21 Sep 2020

56-day deadline 17 Nov 2020

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Incomplete patient medical records led to an inadequate understanding of underlying conditions, resulting in an incorrect anaesthetic choice and monitoring, risking patient safety during procedures.

View full coroner's concerns

A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations
1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk.
2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available.
3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency.

Responses

1 respondent

University Hospitals Plymouth NHS / Health Body

29 Oct 2020 PDF

Action Taken

The trust confirms that all three recommendations regarding the availability of patient records and understanding of patient's underlying conditions have been fulfilled. (AI summary)

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Dear Mr Arrow, Re: Paul Vincent Reynolds (dob. 22 September 1965) University Hospitals Plymouth Dr MBBS MRCP FRCP Medical Director and Cons. Radiologist Department of Clinical Management Level 07 University Hospitals Plymouth NHS Trust Derriford Road Crownhill Plymouth PL6 8DH Tel:

I write in response to the Regulation 28 report dated 21 st September, raising concerns regarding the unavailability of full patient records and incomplete appreciation and understanding of a patient's underlying medical condition. I can confirm that the three recommendations listed in the report have indeed been fulfilled. I hope the above serves to provide assurance around the actions we are taking in respect of the concerns that you have raised and that these will help prevent future deaths of this nature. Yotl?~:--~ Dr

Me,dical Director ?/ cc. , Legal Manager, University Hospitals Plymouth NHS Trust _/MINDFUL VEMPLOYER Working in partnership with the Peninsula Medical School Chairman:

Chief Executive:

Report sections

Investigation and inquest

An Inquest into the death of Paul Vincent Reynolds (dob: 22 September 1965) was opened on 7 January 2020 and heard on 18 September 2020. The Coroner recorded the following NARRATIVE verdict The deceased suffered from learning difficulties and comorbidities which made him vulnerable. He presented to hospital with a swollen hand. One finger became necrotic and required amputation. A decision was made on initial information to carry out surgery on the finger under general anaesthetic. The Deceased's full hospital notes were not available and the deceased had limited discussion with medical staff. The incomplete appreciation and understanding of the patients underlying medical condition led to an inappropriate choice of monitoring and anaesthetic. The deceased suffered a loss of blood pressure and then had a hypoxic period following administration of general anaesthetic. He deteriorated and died from the hypoxic event on 31 December 2019 at Derriford Hospital.

Circumstances of the death

The deceased suffered a hypoxic period following administration of a general anaesthetic.

Action should be taken

Please confirm the recommendations of the Root Cause Analysis have been implemented.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2020-0178
Date of report: 21 September 2020
Coroner: Ian Arrow
Coroner area: Plymouth, Torbay and South Devon

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Nov 2020.

Sent to

Derriford Hospital

Part of a series

2 reports

2021-0151 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.