Source · Prevention of Future Deaths
Roy Burgess
Ref: 2018-0364
Date: 21 Nov 2018
Coroner: Sarah Slater
Area: South Yorkshire (East)
Responses identified: 0 / 2
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The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack of documented doctor input.
Date
21 Nov 2018
56-day deadline
15 Jan 2019
Responses identified
0 of 2
Coroner's concerns
The hospital's Early Warning System was not adhered to, leading to missed senior medical reviews. Inadequate and non-chronological record-keeping by clinicians resulted in a lack of documented doctor input.
View full coroner's concerns
Coroner'$ Court and Office, Doncaster Crown Court; College Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 01302 736365 Roy artery
(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess's care to receive Senior Medical reviews which could have altered his management: (2) Inadequate record keeping by clinician within the Clinical notes_ There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes
e.g: on 4th December 2017,_ Mr Burgess's care was escalated between 11.40 hours and 16.30 hours on at least 5 occasions and no entries were placed in his clinical records_ This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients_ (3) Finally, untimed dictated notes of ward rounds_ were then entered into the records in a non-chronological order; which was unhelpful and potentially misleading
(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess's care to receive Senior Medical reviews which could have altered his management: (2) Inadequate record keeping by clinician within the Clinical notes_ There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes
e.g: on 4th December 2017,_ Mr Burgess's care was escalated between 11.40 hours and 16.30 hours on at least 5 occasions and no entries were placed in his clinical records_ This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients_ (3) Finally, untimed dictated notes of ward rounds_ were then entered into the records in a non-chronological order; which was unhelpful and potentially misleading
Report sections
Investigation and inquest
On 13/12/2017 commenced an investigation into the death of Burgess, 87 . The investigation concluded at the end of the inquest on Wednesday 21 November 2018. The conclusion of the inquest was a Narrative conclusion as follows: Mr Burgess underwent surgery at Doncaster Royal Infirmary on the 3r December 2017 to repair a fracture to his left neck of femur which he sustained in fall at his home on the 1st December 2017 . Post operatively, there were missed opportunities to identify and escalate Mr Burgess's deteriorating condition prior to his death: However it is unlikely that any such interventions would have altered the outcome
Circumstances of the death
Mr Burgess was taken to Bassetlaw Hospital on the Ist December 2017 having suffered a fall in the garden of his home. He was transferred to Doncaster Royal Infirmary on the 2nd December 2017 and he remained there until his death. Cause of death (a) Left femoral fracture (treated) and Ischaemic heart disease (b) Coronary atheroma Advanced age
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Inquest conclusion
Mr Burgess underwent surgery at Doncaster Royal Infirmary on the 3r December 2017 to repair a fracture to his left neck of femur which he sustained in fall at his home on the 1st December 2017 . Post operatively, there were missed opportunities to identify and escalate Mr Burgess's deteriorating condition prior to his death: However it is unlikely that any such interventions would have altered the outcome
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Report details
- Reference
- 2018-0364
- Date of report
- 21 November 2018
- Coroner
- Sarah Slater
- Coroner area
- South Yorkshire (East)
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: 15 Jan 2019.
Sent to
- Department of Health and Social Care
- Doncaster Bassetlaw Teaching Hospital