Source · Prevention of Future Deaths
Ruth Whitmore
Ref: 2019-0473
Date: 6 Feb 2019
Coroner: Jacqueline Lake
Area: Norfolk
0 responses identified · 1 indexed addressee
View PDF
AI-generated concerns summaryThe coroner noted a nurse was unaware of her responsibility for the ward and for initiating an immediate investigation, as this was not clearly communicated at handover. Concerns were also raised about the robustness of the initial investigation, which lacked staff interviews and detailed analysis of events.
Date
6 Feb 2019
56-day deadline
3 Apr 2019
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner noted a nurse was unaware of her responsibility for the ward and for initiating an immediate investigation, as this was not clearly communicated at handover. Concerns were also raised about the robustness of the initial investigation, which lacked staff interviews and detailed analysis of events.
View full coroner's concerns
_ _ (1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed frailty, Leg day to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff.
(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient: No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events_ It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough_
(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient: No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events_ It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough_
Report sections
Investigation and inquest
On 27 April 2018 commenced an investigation into the death of RUTH PATRICIA
Circumstances of the death
Mrs Whitmore had multiple comorbidities and was admitted to Queen Elizabeth Hospital on 1 January 2018. During the early hours of January 2018 Mrs Whitmore was receiving care when her leg became caught in the bed rail causing a large haematoma This is not noted in the records until shortly before handover to the shift. On 10 January the haematoma underwent surgical evacuation and continued to be dressed. Mrs Whitmore was transferred for care in the community, but her condition deteriorated, and she was readmitted to Queen Elizabeth Hospital on 21 March 2018. Sadly, Mrs Whitmore's condition continued to deteriorate, and she died on 13 April 2018.
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
Report details
- Reference
- 2019-0473
- Date of report
- 6 February 2019
- Coroner
- Jacqueline Lake
- Coroner area
- Norfolk
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: 3 Apr 2019 (stated in the report).
Sent to
- Queen Elizabeth Hospital