Source · Prevention of Future Deaths

Taejelle Francois

Ref: 2019-0297 Date: 16 Sep 2019 Coroner: Angela Brocklehurst Area: West Yorkshire (West) Responses identified: 0 / 2 View PDF

A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.

Date 16 Sep 2019
56-day deadline 11 Nov 2019
Responses identified 0 of 2
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
A critically ill patient was taken to the A&E waiting area without visual assessment by reception or triage, missing crucial opportunities for early intervention and escalation of care.
View full coroner's concerns
(1) At the point of admission into the Accident and Emergency Department;, Taejelle was taken into the waiting area without either the Receptionist or the Triage nurse having the opportunity to visually assess despite Tae'jelle medically critical state. Tae'jelle was taken into the waiting area of reception; where she stopped breathing her, being

It was only as a result of the intervention of a member of the public that this condition was discovered, and as a result of that involvement Tae'jelle was taken into the Resus Department; where further treatment failed to revive her_ (2) Evidence was given at the Inquest as to a Guidance recommended by The Royal College of Emergency Medicine upon dealing with the Emergency Assessment of Emergency patients. Such a Protocol provides for Reception to inform the Triage nurse of suspected seriously unwell patient;, with the opportunity of then escalating the treatment of that patient: (3) Evidence was at the Inquest that this opportunity was missed as neither the receptionist nor the Triage Nurse were provided with the opportunity to make the necessary assessment, despite the fact that the Department was not at the time_

Report sections

Investigation and inquest
On 21* November 2017 an investigation into the death of Tae jelle Kaliyah Francois was commenced: - The investigation concluded at the end of the inquest on 4 September 2019. The conclusion of the inquest was a Narrative Conclusion as set out below: Ia - The Medical Cause of Death was Acute Asthma
Circumstances of the death
On the 3" June 2017 Taejelle Kaliyah Francois continued to suffer symptoms of an acute Asthma Attack which had begun several days previously: Despite the use of prescribed medicine her ill health continued and a decision was taken to seek hospital care by her family. During the journey to hospital and whilst waiting for admission Tae'jelle's condition deteriorated critically and she collapsed: Despite receiving appropriate resuscitation treatment she failed to respond and tragically passed away at Huddersfield Royal Infirmary at 22.45 hours that day:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action.

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Report details

Reference
2019-0297
Date of report
16 September 2019
Coroner
Angela Brocklehurst
Coroner area
West Yorkshire (West)

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: 11 Nov 2019.

Sent to

Calderdale and Huddersfield NHS Trust
Chief Coroner

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