Source · Prevention of Future Deaths
Helen Bannister
Ref: 2017-0255
Date: 29 Sep 2017
Coroner: Crispin Butler
Area: Buckinghamshire
Responses identified: 0 / 1
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Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.
Date
29 Sep 2017
56-day deadline
3 Jan 2018 est.
Responses identified
0 of 1
Coroner's concerns
Inaccurate and incomplete records regarding all aspects of care, including fluid intake, diet, and discharge instructions, compromised staff's ability to react properly to a patient's deteriorating condition.
View full coroner's concerns
The Coroner'$ Court; 29 Windsor End Beaconsfield, Buckinghamshire, HP9 2JJ Tel 01494 475505 Fax 01494 673760 and
There was, understandably, a significant volume of documents and records from Lent Rise used to record the various elements of the care Helen Bannister received whilst at Lent Rise. During the course of the investigation and in evidence at the inquest; whilst there was an indication that procedures, documentation and staff awareness has been under review since the death of Helen Bannister, there remains a significant concern that the keeping of accurate records in respect of all aspects of care, fluid intake, diet and nutrition and the proper recording of hospital discharge arrangements and aftercare instructions needs to be improved There remains a continuing risk that the ability of care workers nurses, doctors and hospitals to react properly to unfolding events may be compromised by incomplete records intended to accurately document all actions taken the relevant timings of those actions in the care of a resident.
There was, understandably, a significant volume of documents and records from Lent Rise used to record the various elements of the care Helen Bannister received whilst at Lent Rise. During the course of the investigation and in evidence at the inquest; whilst there was an indication that procedures, documentation and staff awareness has been under review since the death of Helen Bannister, there remains a significant concern that the keeping of accurate records in respect of all aspects of care, fluid intake, diet and nutrition and the proper recording of hospital discharge arrangements and aftercare instructions needs to be improved There remains a continuing risk that the ability of care workers nurses, doctors and hospitals to react properly to unfolding events may be compromised by incomplete records intended to accurately document all actions taken the relevant timings of those actions in the care of a resident.
Report sections
Investigation and inquest
On 2Oth May 2016 | commenced an investigation into the death of Helen Yuk Ying BANNISTER, born on the 8th January 1947_ The investigation concluded at the end of the inquest on 27th September 2017 The conclusion of the inquest was as follows: Medical cause of death: 1a. Sepsis 1b. Bronchopneumonia and peritonitis Ic Recent surgery to insert a gastronomy feeding tube (PEG) The narrative conclusion recorded: On 13th May 2016, Helen Bannister underwent a procedure at Stoke Mandeville Hospital, Buckinghamshire to insert a gastronomy feeding tube (PEG): The loosening of the PEG occurred at some time after discharge from Stoke Mandeville Hospital led to a leak into her abdomen which caused the infection from which Helen Bannister died.
Circumstances of the death
Helen Bannister was a resident at Lent Rise House, part of the Fremantle Trust. Her ability to swallow and take food and drink orally had been becoming compromised and it was agreed she would undergo a procedure as a day patient at Stoke Mandeville Hospital so that she could be fed in future with a PEG feeding regime whilst retaining the ability to take some soft food or liquids orally. The narrative conclusion (above) sets out the brief facts_ After discharge from Stoke Mandeville Hospital, Helen Bannister returned to Lent Rise. At some time during this short period she became ill and this was subsequently identified by Wexham Park Hospital and at post mortem to be due to a leak into her abdomen leading to infection_ She had received emergency treatment; a washout and removal of the PEG at Wexham Park shortly before her death: Section 3 of the Record of Inquest recorded that Helen Bannister died at 0415hrs on 17th May at Wexham Park Hospital, Berkshire as a result of sepsis
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you Fremantle Trust have the power to take such action:
Inquest conclusion
Medical cause of death: 1a. Sepsis 1b. Bronchopneumonia and peritonitis Ic Recent surgery to insert a gastronomy feeding tube (PEG) The narrative conclusion recorded: On 13th May 2016, Helen Bannister underwent a procedure at Stoke Mandeville Hospital, Buckinghamshire to insert a gastronomy feeding tube (PEG): The loosening of the PEG occurred at some time after discharge from Stoke Mandeville Hospital led to a leak into her abdomen which caused the infection from which Helen Bannister died.
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Report details
- Reference
- 2017-0255
- Date of report
- 29 September 2017
- Coroner
- Crispin Butler
- Coroner area
- Buckinghamshire
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 Jan 2018 (estimated).
Sent to
- Fremantle Trust