Source · Prevention of Future Deaths

Carol Harvey

Ref: 2017-0059 Date: 10 Mar 2017 Coroner: John Gittens Area: North Wales (East and Central) 1 response identified · 2 indexed addressees View PDF

AI-generated concerns summaryThe coroner noted a lack of procedures to confirm district nurse referral receipt and action, and delays in implementing a standard operating procedure for safe patient discharge from acute hospitals.

Date 10 Mar 2017

56-day deadline 5 May 2017 est. estimated from the report date

Responses identified 1 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted a lack of procedures to confirm district nurse referral receipt and action, and delays in implementing a standard operating procedure for safe patient discharge from acute hospitals.

View full coroner's concerns

_ (a) That although a referral had been made to the District Nurse Team, there is no procedure in place to ensure that such a referral has been both received and actioned_ Coroner'$ Office County Hall, Wynnstay Road Ruthin;LLIS IYN Tel 01824 708047 Fax 01824 708048 being

(b) The Action Plan which has been produced by the Health Board following an investigation into this death indicates that a Standard Operating Procedure for the safe discharge of patients from the Acute Hospital environment is being developed; however it was not possible to provide a completion and implementation date for this, notwithstanding that the death was eleven months ago. am concerned that delays in undertaking work of this kind could place existing patients at risk.

Responses

1 respondent

University Health Board

Letter dated 5 May 2017 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Health Board stated that the Standard Operating Procedure for the safe discharge of patients from the acute hospital environment is being developed. • A working action plan relating to the case will be monitored at the Secondary Care QSE meeting in July 2017 to ensure timely progress and completion.

View full response

Dear Mr Gittins Re: Regulation 28 letter in respect of Carol Ann Harvey Further to your Regulation 28 notification to the Health Board following the inquest of Carol Ann Harvey: The Health Board has considered your concerns in relation to problems identified that: "Although a referral had been made to District Nurse Team, there is no procedure in place to ensure that such a referral has been both received and actioned. The action plan which has been produced by the Health Board following an investigation into this death indicates that the Standard Operating Procedure for the safe discharge of patients from the acute hospital environment is being developed; however it was not possible to provide a completion and implementation date for this, notwithstanding that the death was eleven months ago_ am concerned that delays in undertaking work of this kind could place existing patients at risk' Please therefore find enclosed working action plan relating to this case which will be monitored at the Secondary Care QSE meeting in July 2017 to ensure timely progress and evidence of completion: The accountable officer for the action plan will be the Director of Nursing for Secondary Care.

Report sections

Investigation and inquest

On 12/04/2016 commenced an investigation into the death of Carol Ann Harvey, (DOB 6.4.42 DOD 9.4.16) The investigation concluded at the end of the inquest on the 7lh of March 2017 The conclusion of the inquest was by way of a Narrative Conclusion as set out in paragraph 4 below

Circumstances of the death

Carol Ann Harvey was a seventy four year old lady who had been receiving medical treatment at the Wrexham Maelor Hospital. By the 6th of April 2016 plans were being made for her discharge home with care and support provided to her by her family, carers and district nurses_ On the 6th of April 2016 here INR was higher than was clinically ideal and this was being addressed by a reduction in her dosage_ At around 4.15pm on the 7th of April 2016, following a delay arising from some confusion relating to a Tissue Viability Review, confirmation was received that Carol was to be discharged and a telephone call was made to the generic health care team t0 advise them of this so that the care plan could commence A message was left on an answerphone to this effect but no confirmation was obtained that these instructions had been received. The answerphone was not checked until the following morning, notwithstanding that staff had returned to the office briefly around 7.OOpm that evening: No carers attended Carol Harvey during the evening of the 7th of April and it is probable that in the course of that evening and overnight she was in considerable pain as a result of a calf haematoma and consequently took an accidental overdose of painkillers_ At around 7.40am on the &h of April she was found, drowsy and vomiting and she had suffered a large loss 0f blood which necessitated her readmission to hospital_ Despite appropriate treatment for her condition she continued to decline and passed away at the Maelor Hospital in the early hours of the gth of April 2016 due to a combination of the effects of the paracetamol overdose and a pre-existing cardiac condition:

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

Shared signals

Report details

Reference: 2017-0059
Date of report: 10 March 2017
Coroner: John Gittens
Coroner area: North Wales (East and Central)

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 May 2017 (estimated from the report date).

Sent to

Betsi Cadwaladr University Health Board

Ysbyty Gwynedd

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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