Source · Prevention of Future Deaths

Howard Winter

Ref: 2018-0040 Date: 8 Feb 2018 Coroner: Graeme Hughes Area: South Wales Central Responses identified: 1 / 1 View PDF

An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.

Date 8 Feb 2018

56-day deadline 2 Aug 2018 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

An auxiliary nurse's recording of a patient's neck pain was not escalated to a doctor for further assessment, potentially delaying diagnosis of a cervical spine fracture.

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When Mr Winter attended at A & E on 23 & 26.8.17, he was diagnosed with a subdural haematoma following a CT scan head. It was not until after a CT scan of his spine was undertaken on 11.9.17 that he was diagnosed with a cervical spine fracture. The question arose as to whether; & following his initial presentation on 23.9.17 & admission on 26.8.17 there was any evidence of symptoms of neck pain which could have given rise to earlier investigations into, & possible earlier diagnosis of the cervical spine fracture. Igave evidence at the Inquest that on the 26.8.17 an auxiliary nurse had Tecorded in the nursing notes 'pain in necklback ~ unable to score There was no evidence written or othenwise_to demonstrate an escalation of this finding_to a doctor the for re-assessment; investigation & diagnosis levidence to Inquest was that this ought to have occurred Whilst this apparent absence of escalation may not necessarily have affected outcome for Mr Winter; were it to be repeated nOw, or in the future; the outcome for the patient involved could be potentially causative oflcontribute towards deathladverse outcome;

Responses

1 respondent

University Health Board

19 Mar 2018 PDF

Action Taken

Cwm Taf University Health Board has undertaken two audits of NEWS scores, identified the need for further education and training, and is monitoring improvement work via the quarterly quality report. (AI summary)

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Dear Mr Barkley RE: Regulation 28 for Howard Winter Thank you for the correspondance in relation to the above Regulation 28 received on February 2018, which was also sent to the Health Board CEO Mrs Allison Williams Please note that I have discussed the content of your letter with both the CEO and the Director of Nursing: In relation to improvement work being undertaken within Cwm Taf University Health Board regarding NEWS wish to assure you that the following work has taken place:
1. Two audits have been undertaken across the Health Board to measure how the NEWS scores are completed and escalated. 2 We have a University Health Board Clinical Lead for the RRAILS (Rapid Response to Acute illness Learning Set) who is a Consultant Anaesthetist ad also the National Lead overseeing this important piece of work The audit has identified the need for further education and training as well as raising awareness amongst nursing and medical staff in relation to accurate documentation and escalation: The audit has also identified priority clinical areas for improvement work which will be progressed. Monitoring of the improvement work is undertaken via the quarterly quality report to the Quality & Risk Safety Committee: hope that I have provided assurance to you that your concerns are being dealt with in the University Health Board as part of our ongoing Quality Delivery Plan. RECEIED LU MAR 2018 Kind Regards Return Address: Cwm Taf University Health Board, Headquarters, Navigatioh Park,Abercynon; CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prlfysgol Cwm Taf 14th

Vamal Mr Kamal Asaad Medical Director Cwm Taf University Health Board Cc: Mrs Allison Williams, CEO, Cwm Taf UHB Mrs Lynda Williams, Director of Nursing & Midwifery Services, Cwm Taf UHB

Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park; Abercynon, CF45 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Taf Universlty Health Board Is the operational name of the Cwm Taf Unlverslty Health Board/Bwrdd lechyd Prifysgol Cwm Taf Yw enw gwelthredol Bwrdd lechyd Prifysgol Cwm Taf Ascad

Report sections

Investigation and inquest

On the 21* September 2017 | commenced an investigation into the death of Howard Winter aged 85. The investigation concluded at the end of an inquest on 1* February 2018. The medical cause of death was Ia. Hospital Acquired Pneumonia, 1b C5-6 vertebral fracture with cord injury, alongside subdural bleeding in the setting of a person with ankylosing spondylitis, Ic Recurrent Falls & 2. Vascular Dementia. The conclusion of the inquest was Accidental Death

Circumstances of the death

The deceased was a resident at the Daffodils CH, Merthyr Tydfil. He suffered from vascular dementia & had frequent falls. On 23.8.17 he fell in his room, sustained a serious head injury & was taken to PCH, Merthyr Tydfil On 11.9.17 he was diagnosed with a fractured spine: He developed pneumonia & died there on 16.9.17

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.

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Report details

Reference: 2018-0040
Date of report: 8 February 2018
Coroner: Graeme Hughes
Coroner area: South Wales Central

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: 2 Aug 2018 (estimated).

Sent to

CWM Taff University Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.