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Mary Johnson

Ref: 2019-0495-wp26975 Date: 1 Feb 2019 Coroner: Hugh Bricknell Area: Herefordshire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted a lack of communication among staff regarding pre-operative patient feeding and medication adherence, alongside concerns that porter availability affected the hospital's capacity to perform operations.

Date 1 Feb 2019
56-day deadline 29 Mar 2019 est. estimated from the report date
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner noted a lack of communication among staff regarding pre-operative patient feeding and medication adherence, alongside concerns that porter availability affected the hospital's capacity to perform operations.
View full coroner's concerns
In the circumstances it is my statutory to report to you: (1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant's instructions regarding provision of medication prior to operation (2) It was suggested that the availability of porters determined ability of the hospital theatres to out operations Town Hall, St Owen Street; Hereford, HRI 2PJ Tel 01432 261813 Fax 01432 261720 the Mrs Mary duty the the carry

Responses

1 respondent

Wye Valley NHS Trust

NHS Trust
PDF
AI-classified response stance Action Taken
AI-generated response summary

• The use of thromboprophylaxis to surgery, including the time period for withholding, has been relaunched and clarified to all pertinent staff. • All speciality-specific thromboprophylaxis guidelines are currently under review.

View full response
Dear We stay Tues July

Although not actually the root cause for this patient's death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis to surgery, particularly the time period before which it should be withheld. In addition to and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and would be happy to update you on the progress of this a later date_ trust this answers all the outstanding questions you have for this sad case but would be more than happy to meet with you in person to clarify any other details. Best wishes

Report sections

Investigation and inquest
On the Ist day of August 2018 commenced an investigation into death of Mary Bertha Johnson
Circumstances of the death
Bertha Johnson died on the 25th July 2018 at the County Hospital, Hereford, Mrs Johnson had fallen on the 2Oth July 2018 causing a periprosthetic fracture of the femur:
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:

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Report details

Reference
2019-0495-wp26975
Date of report
1 February 2019
Coroner
Hugh Bricknell
Coroner area
Herefordshire

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: 29 Mar 2019 (estimated from the report date).

Sent to

Wye Valley NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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