Source · Prevention of Future Deaths
Derek Turnbull
Ref: 2017-0076-wp25690
Date: 16 Mar 2017
Coroner: Derek Winter
Area: Sunderland
Responses identified: 0 / 1
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There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.
Date
16 Mar 2017
56-day deadline
11 May 2017 est.
Responses identified
0 of 1
Coroner's concerns
There was an hour-long delay in calling an ambulance for a patient with a head injury and known fall risk, despite clear need for immediate hospital transfer, indicating a failure in protocols for urgent escalation.
View full coroner's concerns
In the circumstances it is my statutory to report to you: Mr Derek Wynne Turnbull had a known history of falls, was on Warfarin and had sustained an obvious head injury after an unwitnessed fall, yet it took from 03:1Sam to 04:1 Sam to summons an ambulance by a 999 call in a case that was to be stepped up" to hospital in any event. There was no purpose in waiting; given the known scenario. In Mr Turnbull' $ case the may not have caused or contributed to his death; but in other cases the opportunity for earlier review at the hospital ought to be taken. Policies, procedures and protocols may need to be reviewed in order to ensure that in cases that are to be stepped up, that the action is taken immediately_
Report sections
Investigation and inquest
On 10t August 2016 Mr Derek Wynne Turn 86 years died at Sunderland Royal Hospital: I concluded the Inquest as part of my investigation on 15th March 2017 recording a conclusion of an Accident: The Cause of Death following Post-Mortem Examination was: Ia Bilateral Bronchopneumonia; Contributed to by
Circumstances of the death
Mr Derek Wynne Turnbull had been a resident at the ICAR Unit since st August and he had a recognised risk of falls. He was on Warfarin. On 9uh August 2016 Mr Turnbull was seen by a member of staff at 02:3Oam. Staff were alerted by an alarm in Mr Turnbull'$ room that he was mobile at 03:1Sam and discovered him face down on the floor_ His fall was not witnessed. Staff attended to Mr Turnbull's facial injuries and, although he was observed, an ambulance was requested to take him to hospital until 04:1 8am. Paramedics attended to Mr Turnbull at 04.35am and transported him to Sunderland Civic Centre_ Burdon Road_ Sunderland, SRZ 7DN Tel 0191 5617843 Fax 0191 5537803 DX 60729 Sunderland WWW.sunderlandcoroner.co.uk part/ aged not
Royal Hospital Emergency Department by 05.24am. Mr Turnbull had a CT Scan at 05.48am, and at 07:19am he was given Beriplex to reverse the effects of Warfarin: Mr Turnbull had a acute-on-chronic subdural haemorrhage and surgical intervention was not an Mr Turnbull was made comfortable and passed away n 1Oth August 2016 at 08:1 Spm:
Royal Hospital Emergency Department by 05.24am. Mr Turnbull had a CT Scan at 05.48am, and at 07:19am he was given Beriplex to reverse the effects of Warfarin: Mr Turnbull had a acute-on-chronic subdural haemorrhage and surgical intervention was not an Mr Turnbull was made comfortable and passed away n 1Oth August 2016 at 08:1 Spm:
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.
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Report details
- Reference
- 2017-0076-wp25690
- Date of report
- 16 March 2017
- Coroner
- Derek Winter
- Coroner area
- Sunderland
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: 11 May 2017 (estimated).
Sent to
- Gateshead Health Foundation Trust