Michael Newell

In the circumstances it is my statutory to report to you: (1) the Accident & Emergency staff, neurosurgeons and ENT surgeons of various grades were unaware of the substantial effect that Mr Newell's decompensated liver failure would have on his clinical course and subsequent management: No input was sought from any medical team to assist in the management prior to Mr Newell's first collapse at 11:14 AM on 5 May 2014. This lack of awareness raises significant concerns about the knowledge base of Accident & Emergency and surgical junior staff of the significant effect of substantial underlying hepatic compromise may have on any form of admission with some form of haemorrhage_ As a result, the family were completely unaware of the significance of Mr Newell's admission due to the lack of awareness by attending clinicians. (2) thejunior ENT surgeons and neurosurgeons showed a startling lack of knowledge of the early signs of hypovolaemia and, if any did realise, made no attempt to treat Mr Newell adequately: Whilst this PFD report is primarily sent with regard to the death of Mr Newell, this has been a feature over a number of years of other cases where hypovolaemia was not appropriately diagnosed and late resuscitation ensued: (3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing_haemorrhage,decompensated liver failure and associated coagulopathy_that there Coruncr' $ Court; 2 Farudoy Court; Furnduy Drive; Fulwood, Prcston; Lancashire, PR2 9NB Tcl 01772 703700 Fox 01772 704422 aged paid May duty were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack5 that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures: Firstly, there was no consultant ENT input into Mr Newell's case at any prior to his death: Secondly, none of the above issues were brought to the attention of the Court in the ENT consultants statement raising issues within the Trust for improving patient care_ (4) the Trusts ENT team made no input into the mortality review prior to it reaching its conclusions: Alternatively, the mortality review team made no request for ENT input prior to reaching its conclusions Either formulation reduces the effectiveness of the mortality review: (5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management; not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed: