Source · Prevention of Future Deaths
Terence Bradfield
Ref: 2019-0086
Date: 11 Mar 2019
Coroner: Deborah Archer
Area: Plymouth Torbay and South Devon
Responses identified: 0 / 1
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Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.
Date
11 Mar 2019
56-day deadline
6 May 2019
Responses identified
0 of 1
Coroner's concerns
Failures in steroid administration, prescription, and staff training on steroid management were identified. There was also a lack of policy on steroid use and insufficient staff understanding of "Nil by Mouth" for complex patients.
View full coroner's concerns
(1) They are Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting Mr. Bradfield was not on a stress dose of steroids whilst in Derriford hospital The awareness and training of staff on the issue of steroid management: from taking put
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of CO morbidities are present despite this death having arisen in 2013. The training and awareness of staff on the meaning of Nil by Mouth in patients who are suffering from a number of co ~morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting Mr. Bradfield was not on a stress dose of steroids whilst in Derriford hospital The awareness and training of staff on the issue of steroid management: from taking put
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of CO morbidities are present despite this death having arisen in 2013. The training and awareness of staff on the meaning of Nil by Mouth in patients who are suffering from a number of co ~morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures
Report sections
Investigation and inquest
On 16h April 2018 an inquest was opened into the death of Terence Bradfield age 70 dob 09.07.43 The investigation concluded at the end of the inquest on 1st March 2019. The conclusion of the inquest was that Mr Bradfield died Ia Small intestinal infarction 2 Pulmonary Sarcoidosis , Hospital acquired pneumonia, duodenal ulcer:
Circumstances of the death
On 1st December 2013 Mr Bradfield entered Derriford hospital with Gastric bleeding: He had been steroid medication prescribed for Sarcoidosis for over 20 years Mr Bradfield died on 17th December 2013 primarily from the consequences of his GI bleed but during his inpatient stay there were occasions when his steroid dose was either not given or adequately managed.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action. ask you to review my concerns and report on any action taken to address those concerns_
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Report details
- Reference
- 2019-0086
- Date of report
- 11 March 2019
- Coroner
- Deborah Archer
- Coroner area
- Plymouth Torbay and South Devon
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 May 2019.
Sent to
- University Hospitals Plymouth NHS Trust