Source · Prevention of Future Deaths
Christina Witney
Ref: 2017-0112
Date: 7 Apr 2017
Coroner: Ian Singleton
Area: Wiltshire and Swindon
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryConcerns relate to the accuracy of patient record keeping, particularly for urine output, and the timeliness of patient reviews when there is no improvement in condition. The coroner also noted the need to review sepsis guidelines and the training provided to locum and temporary staff.
Date
7 Apr 2017
56-day deadline
2 Jun 2017
stated in the report
Responses identified
0 of 2
Coroner's concerns
Concerns relate to the accuracy of patient record keeping, particularly for urine output, and the timeliness of patient reviews when there is no improvement in condition. The coroner also noted the need to review sepsis guidelines and the training provided to locum and temporary staff.
View full coroner's concerns
_ (1) The keeping of patient records in relation to a urine chart and the accurate measuring of output: (2) The period before a review of a patient is carried out where there has been no improvement in condition_ (3) Review of the sepsis guidelines in the light of the Acute care toolkit 9: sepsis" produced by The Royal College of Physicians (4) The training of locums and other temporary staff
Report sections
Investigation and inquest
On 17 September 2015 an investigation was commenced into the death of Christina Bernadette Withey aged 70. The investigation concluded at the end of the Inquest with on 31 March 2017, having heard evidence on 28,29, 30 and 31 March 2017_ The conclusion of the Inquest was one of a narrative_
Circumstances of the death
Christina was an inpatient at Great Western Hospital, having been admitted on the 10 September 2015_ with abdominal pain, constipation and pyrexia: At some either late on the 14 September or during the 15 September 2015 Christina suffered a stercoral perforation leading to faecal peritonitis, sepsis and multi organ failure which caused her death on the afternoon of 15 September 2015.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Similar PFD reports
Report details
- Reference
- 2017-0112
- Date of report
- 7 April 2017
- Coroner
- Ian Singleton
- Coroner area
- Wiltshire and Swindon
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Jun 2017 (stated in the report).
Sent to
- Great Western Hospitals NHS Trust
- NHS England