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Peter Knight

Ref: 2019-0219 Date: 18 Mar 2019 Coroner: Jacqueline Lake Area: Norfolk Responses identified: 1 / 1 View PDF

The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.

Date 18 Mar 2019
56-day deadline 9 Sep 2019 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
View full coroner's concerns
At the inquest was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant: It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy: Not having heard from the Trust, my Officer contacted the Trust today: A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced. Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April; am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced:

Responses

1 respondent
The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust NHS / Health Body
8 May 2019 PDF
Action Taken

The Trust revised its Transfer of Patients Policy, ratified on May 7th, and delivered "Transferring the Critically Ill Patient" training including a decision to not transfer patients on Hi Flo airvo2 without battery backup. They also redesigned transfer stickers using an SBAR format. (AI summary)

View full response
Dear Mrs Lake Regulation 28 in the matter of Mr Peter Knight (deceased) "m writing to say that am now able to respond to your Regulation 28 report dated 18 March with respect to the Transfer of Patients Policy. In order to do this attach a timeline of the events which have taken place since Mr Knight's sad death and a copy of the policy itself which was ratified at the Clinical Governance Committee meeting on 7th May: can also advise that have visited the Knight family to apologise for the care and subsequent death of Mr Knight and for the way the family was treated It was totally unacceptable. have asked Jand the family to attend our next Board meeting to share their experience if they feel they can do so. We have also promised to keep in close touch with the family throughout this difficult time hope that this reply gives you some level of assurance of the seriousness the Trust has applied and the learning needed in going forward.

Report sections

Investigation and inquest
On 19/06/2018 commenced an investigation into the death of Peter David KNIGHT aged 70. The investigation concluded at the end of the inquest on 15/01/2019. The conclusion of the inquest was; Accident; The medical cause of death was: 1a Acute Exacerbation of Idiopathic Pulmonary Fibrosis 1b 1c Il Ischaemic Heart Disease
Circumstances of the death
Mr Knight had a long-standing history of idiopathic pulmonary fibrosis and was oxvgen dependent: He was admitted to the Queen Elizabeth Hospital on 5 June 2018 and was diagnosed with a chest infection. On 6 June 2018 Mr Knight was transferred from the Medical Assessment Unit to Necton Ward during which time he was not connected to portable cylinder oxygen: On arrival on the he was seen to be hypoxic and despite being given oxygen, Mr Knight died later that evening:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:

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Report details

Reference
2019-0219
Date of report
18 March 2019
Coroner
Jacqueline Lake
Coroner area
Norfolk

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: 9 Sep 2019 (estimated).

Sent to

Queen Elizabeth Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.