Source · Prevention of Future Deaths

James O’Brien

Ref: 2017-0082 Date: 13 Mar 2017 Coroner: Philip Barlow Area: London Inner (South) Responses identified: 1 / 1 View PDF

Critical delays in emergency response, including resuscitation and defibrillator deployment, were compounded by inadequate staff training, poor induction for agency nurses, and insufficient information provided to ambulance services.

Date 13 Mar 2017

56-day deadline 10 May 2017

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ There was a failure to press the alarm There was a of about minutes in starting resuscitation: There was a of about 6 minutes in calling the ambulance There was a of about 8 minutes in bringing the defibrillator: The defibrillator was not attached appropriately Inadequate information was given to the London Ambulance Service. There was a failure to ensure that staff were adequately trained to respond to an emergency situation:
8) There was a failure to provide adequate induction to staff. The agency nurse in charge of the ward was called shortly_ before the shift started, The The delay delay delay was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties_

Responses

1 respondent

Cambian Group PLC Other

30 Mar 2017 PDF

Action Taken

Cambian Group sold Cambian Healthcare Limited in December 2016, so the response was forwarded to Cygnet Healthcare Limited. RadcliffesLeBrasseur, acting for Cambian Adult Services, outlines existing practices including staff tours for familiarity, prioritising internal/bank staff over agency, and an agency nurse induction protocol. The NEWS system has also been introduced at the hospital with staff training. (AI summary)

View full response

Dear Mr Barlow Inquest into_the death of James 0'Brien am writing to you as the Chief Executive of Cambian Group PLC_ refer to your Regulation 28 report dated 13th March 2017 issued following the conclusion of the Inquest into death of Mr 0' Brien: The Churchill Hospital was at the date of Mr 0'Brien's death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited: The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Romero. have therefore passed your letter to Dr Romero, who know is arranging for a response to your report to be sent to you today, addressing the issues that you have raised. Please let me know if you have queries and will be happy to assist_

Report sections

Investigation and inquest

On 14 December 2015 commenced an investigation into the death of James O'Brien, age25. The investigation concluded at the end of the inquest on 3 March 2017 The conclusion of the inquest was that Mr O'Brien died of natural causes_ The medical cause of death was sudden cardiac death in schizophrenia. jury's conclusion at the end of the inquest was that when Mr O'Brien was found to have collapsed the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

Circumstances of the death

Mr O'Brien had been a patient at Churchill Hospital since March 2014 under s3 MHA On the night of 8/9 December 2015 he was found collapsed in his room on Juniper ward. Attempts at resuscitation were made by staff and London Ambulance Service paramedics_ He was taken to St Thomas' Hospital where he was died on 9 December

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 Regional Operations Director; attended the inquest and gave evidence of changes that have been made since this incident: However; in light of the jury's conclusions, have no doubt that Cambian will wish to review their systems and policies to check are sufficiently robust to minimise the risk of repetition.

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Report details

Reference: 2017-0082
Date of report: 13 March 2017
Coroner: Philip Barlow
Coroner area: London Inner (South)

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: 10 May 2017.

Sent to

Cambian Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.