Source · Prevention of Future Deaths

Peter Knight

Ref: 2019-0219 Date: 18 Mar 2019 Coroner: Jacqueline Lake Area: Norfolk 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted delays in the completion and trial of a new policy for transferring oxygen-dependent patients, which was not finalised by the agreed deadline following the inquest.

Date 18 Mar 2019

56-day deadline 9 Sep 2019 est. estimated from the Judiciary.uk publication date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted delays in the completion and trial of a new policy for transferring oxygen-dependent patients, which was not finalised by the agreed deadline following the inquest.

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 Trust

Letter dated 8 May 2019 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Transfer of Patients Policy was ratified at the Clinical Governance Committee meeting on 7th May. • The Trust stated it had visited the family to apologise for the care provided and their treatment. • The Trust indicated it had invited the family to attend a Board meeting to share their experience.

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:

Similar PFD reports

Shared signals

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 from the Judiciary.uk publication date).

Sent to

Queen Elizabeth Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.