Source · Prevention of Future Deaths
Clive Davies
Ref: 2017-0074
Date: 16 Mar 2017
Coroner: Andrew Barkley
Area: South Wales Central
Responses identified: 0 / 3
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Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
Date
16 Mar 2017
56-day deadline
7 Jun 2017
Responses identified
0 of 3
Coroner's concerns
Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
View full coroner's concerns
the matters of concern as follows
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming.
Report sections
Investigation and inquest
On the 7th September 2016 I commenced an investigation into the death of Clive Davies. The investigation concluded at the end of an inquest on the 15th March 2017. The conclusion of the inquest was that of a narrative conclusion “Clive Davies died from the complication of a head and neck injury which he sustained when he fell down the stairs at his home address. The precise cause of the fall is unknown but is likely to have been due to the medical condition which he suffered with.”
Circumstances of the death
The deceased, who was known to have fallen several times since January 2016 and who was generally in poor health, fell down the stairs at his home address on the 22nd August 2016 he was conveyed to the Royal Glamorgan Hospital where a CT scan revealed serious head injury (Intraventricular Haemorrhage) and a Cervical Spine Fracture. Initially his observations were stable but a noticeable deterioration occurred on the 24th August where upon a further CT head scan took place which revealed progression of the intracranial bleed. He was not deemed suitable for surgical intervention. His condition fluctuated and he appeared to be making some progress although his family maintained that he was deteriorating throughout his hospital admission. In the early of 30th August he was found unresponsive in his bed and could not be revived. He was declared deceased shortly after.
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Report details
- Reference
- 2017-0074
- Date of report
- 16 March 2017
- Coroner
- Andrew Barkley
- Coroner area
- South Wales Central
Responses identified
Responses identified
0 of 3
3 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Jun 2017.
Sent to
- Cwm Taf Morgannwg University Health Board
- The Chief Coroner
- Welsh Assembly Government