Source · Prevention of Future Deaths

Stephen Taylor

Date: 1 Nov 2018 Coroner: Andrew Cox Area: Worcestershire Responses identified: 1 / 1 View PDF

Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.

Date 1 Nov 2018

56-day deadline 27 Dec 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.

View full coroner's concerns

Curing tne course of tha inquest the ewidence revealed matcr? givinig ESE lo corcern In m} cpinion there is a risk tnat future deains accur Urless action I5 laken Inthe circumstances it is my Btatutcry Culy t3 rpon [o YDu the hia He will

The MATTERS QF CONCERN ar0 a5 Icllows {1} heard U eviderca #rom Mr Young, the Tnusts Clinical Director wno had carred cula Rool Cause Analysis heard also irom one of Trusr8 consultanineurosurgeons Both corsuliants expressed their balief that neurosurgical palionts 0l Ihis nalure requlred additional support ircm their ccnzuttant phys clan collaagues was Iold Inat this has been an issue fOr 3cM0 time and remained unresolved In parcular, Inere was concern ihat a junior neurosurgical doctor w3s left to implementan a cohol wlthurawal regMen Was tald that these difficulties are nct confined t0 patients who are admllled with alcchol-ralated iesues bui extend acro35 whcle range cfneurosurgical patlents who require madical input (21 was told thal the alcanol wilhdrawal protocol was difficult to uriderstand This resuiled In Ihe doclor prescribirg diazepam wnen L orazapam should ceen Used, was Icld and shown an acton plan that the Trust intend: t0 implement lo Improve Ihe pocess

Responses

1 respondent

Stephen Taylor

10 Dec 2018 PDF

Action Taken

The Trust uses electronic referral systems and junior doctor rotations for multi-specialty opinions. They have already supplemented their Care of the Elderly team with Advanced Nurse Practitioners to support complex surgical patients and plan to further increase this provision. (AI summary)

View full response

Dear Sir,

Thank you for your letter of 1 November 2018. I note that you have raised a Regulation 28 Report to prevent future deaths at University Hospitals Coventry and Warwickshire NHS Trust following the inquest surrounding the death of Stephen Allan Samuel Taylor. In particular, you have requested me, as the Chief Medical Officer, to review whether there is adequate support for neurosurgical patients who also have medical co-morbidities and if not, how this situation may be best addressed.

At University Hospitals Coventry and Warwickshire NHS Trust we have an electronic referral requesting system in place whereby opinion of medical staff in different specialties can be sought. This applies to all staff in all wards. For instance, the doctors working on the neurosurgical ward have this system in place where they could request for their patients to be seen by doctors from other specialties as necessary. Furthermore, junior doctors rotate through different medical specialities during their training to gain competencies in management of chronic medical conditions.

As a Trust we have looked to support complex surgical specialties, such as Neurosurgery, Vascular Surgery and Orthopaedics with provision of specialist medical opinion, especially from Care of the Elderly physicians. However, due to a national shortage of consultants in this specialty, we have supplemented our Care of the Elderly team with Advanced Nurse Practitioners. We will be looking to increase this further so as to provide specialist medical input to surgical patients with medical co- morbidities.

Kind Regards

Report sections

Investigation and inquest

In August 2018 an inquest wa8 opened into dealh cl Mr Taylor Wno died on 31 July 2018 The inqucst concluded at a heanng on 31 Oclober 2018 whera it wJ3 found that Mr Taylar had dled a5 tha resuli Dfan accident The causa of death given &t inquest "as Jajsepsis; ibj chest infection; 1c) nead Injury I) chraric obstructive pulmonary disease

Circumstances of the death

Or 27 July ZD18 Mr Taylor suffered a fall at his hcme eddress wnd strjck his head, He was taken to the Alexandra Hospital where a CT cf hia head revealed a large azute haematoma After manzgement cf concition and 2 lurkei CT scan he was transferred to your Trust in the eaily hours 0f 28 July 2018 Following nis admisslon It was roted Inat Mr Taylor displayed signa of agtation ond tremors selzures. Il was falt Inat this wias likely to be related to alcchol withdrawal The dacior revicwed thz Trusts protocol tne management ofsuch patients and,In ercl, Frescnbed and acmiristerad Diazepam Cn 29 July ?018 Mr Taylor guffered 3 respiratory arrest was gwen an anlagonist and rerovered promptly to hiz pre-arrest condilion Sadly Mr Tay%t developed a chest infection &nd,despite treatment subsequenlly Gelarioraled and cied in the Trubt on 31 July: One of tho matters inwoslgaled altte inquest was whetner 35 8 Conbequence of Ine respiratory arresl Mr Taylor had aspialad 45 amatter of fact t wJz found tnal tho aspiralon had occuirad at Iha bme Df the triginal fall,

Action should be taken

In my opinian acuon should be Iaken to prevent future deaths and believe you havo Ihe powa: to lake such acton would ba grateful ii You would review' whethor there is adequate sunport for neurosurgical patients "hj alsc have medical co-mcrblolties If ihere i5 rct, would be gratejul if you would consider how Ihal situation may best be adressed

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Report details

Date of report: 1 November 2018
Coroner: Andrew Cox
Coroner area: Worcestershire

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: 27 Dec 2018 (estimated).

Sent to

University Hospital Coventry and Warwickshire NHS TRUST

Part of a series

2 reports

2026-0020 All responses identified

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.