Dudley Group NHS Trust
NHS / Health Body
Action Taken
The Trust completed a Root Cause Analysis (RCA) and has an action plan that confirms actions taken subsequent to the investigation, addressing concerns about contacting doctors, record keeping, and communication with family. (AI summary)
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Dear Mr Siddique,
Re: Response to Regulation 28 Report to Prevent Future Deaths – The late Mr Ronald Compson
I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 18 January 2018, in respect of the late Ronald Compson. I should extend again the condolences of the Trust to Mr Compson’s family.
The MATTERS OF CONCERN are as follows:
1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on-call Doctor.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.
The enclosed action plan confirms the actions taken subsequent to the investigation and target dates for completion of those actions.
I trust the information provides assurances to you that The Dudley Group NHS Foundation Trust has taken appropriate action to address the matters of concern raised.
Re: Response to Regulation 28 Report to Prevent Future Deaths – The late Mr Ronald Compson
I am in receipt of your Regulation 28 Report to Prevent Future Deaths following the inquest and your ruling on 18 January 2018, in respect of the late Ronald Compson. I should extend again the condolences of the Trust to Mr Compson’s family.
The MATTERS OF CONCERN are as follows:
1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on-call Doctor.
2. There were two separate incidents of vomiting and poor record keeping of when these occurred.
3. There was poor communication to the family about the initial fall.
The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.
The enclosed action plan confirms the actions taken subsequent to the investigation and target dates for completion of those actions.
I trust the information provides assurances to you that The Dudley Group NHS Foundation Trust has taken appropriate action to address the matters of concern raised.