Source · Prevention of Future Deaths
Kathleen Cooper
Ref: 2017-0063
Date: 8 Mar 2017
Coroner: Lisa Hashmi
Area: Manchester City
Responses identified: 0 / 2
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A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and missed opportunities to treat the deceased, and poor communication between clinicians and nurses.
Date
8 Mar 2017
56-day deadline
3 May 2017 est.
Responses identified
0 of 2
Coroner's concerns
A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and missed opportunities to treat the deceased, and poor communication between clinicians and nurses.
View full coroner's concerns
of the inquest the evidence revealed matters giving rise to concern ; In my opinion there is During the course unless action is taken. In the circumstances it is my statutory duty to a risk that future deaths will occur report to you. Department of_Health: During the course of the inquest; a medical practitioner raised concerns regarding the difficulties previdingesafe and effective care where a acute NHS Trust has & numbeno6 faced by clinicians in different sites i.e; the difficuities faced as a result of split-site commitments hospitals/departments on as a result of NHS reconfiguration. echo this concern standard of care provided to hospital patients out of hourshweekend ad the riskls posed to The patient safety as a result. Pennine Acute Hospitals NHS Trust: process identified significant number of errors omissions and missed
3. The RCA and the inquest which, on the balance of probabilities, could and would opportunities to treat the deceased all of cO-morbidities_ Most of naverimproved the deceaseds chances of survival, despite her pre-existing Trust identified in this case have been recognised in previous RCAs conducted by the the failings months. Despite evidence as to 'lesson learned laction plans set etc flowing over the last 6-12 being made in terms of improving/driving therefrom, there appears to be little (if any) timely progress particular: standards and preventing future deaths My concerns relate to the following in up care Poor communication bylbetween clinicians and nurses Poor record keeping medical and nursing Poor leadership/supervision of nurses Ward/Matron level not day,
Inadequate supervision by on-call consultants of junior colleagues Incorrectly calculated early warning scores Besealcudtior atioaslvotzecordedlinaccurately recordimissing vital parameters (impacting the calculation of early scores) outwith Trust guidanceldeviation from upon clinically justified the same not Inaccurate fluid balance charts (persistent basic arithmetical errorsllack of recording) absence of clinical judgement as a result of the over-reliance placed tools early warning scores upon such as the Failure to repeat tests such as bloods and to act upon the results accordingly Cliicze condsfalate (by doctors and nurses) when signs of deterioration/change clinical condition become apparent in the patient's Doocs anarvaagingolrgentadditional tests and treatment (in this case radiological CT scanning; bloods and IV antibiotics) Split site commitmentireconfiguration and the impact this potentially has clinical care (please see above): upon patient safety and
3. The RCA and the inquest which, on the balance of probabilities, could and would opportunities to treat the deceased all of cO-morbidities_ Most of naverimproved the deceaseds chances of survival, despite her pre-existing Trust identified in this case have been recognised in previous RCAs conducted by the the failings months. Despite evidence as to 'lesson learned laction plans set etc flowing over the last 6-12 being made in terms of improving/driving therefrom, there appears to be little (if any) timely progress particular: standards and preventing future deaths My concerns relate to the following in up care Poor communication bylbetween clinicians and nurses Poor record keeping medical and nursing Poor leadership/supervision of nurses Ward/Matron level not day,
Inadequate supervision by on-call consultants of junior colleagues Incorrectly calculated early warning scores Besealcudtior atioaslvotzecordedlinaccurately recordimissing vital parameters (impacting the calculation of early scores) outwith Trust guidanceldeviation from upon clinically justified the same not Inaccurate fluid balance charts (persistent basic arithmetical errorsllack of recording) absence of clinical judgement as a result of the over-reliance placed tools early warning scores upon such as the Failure to repeat tests such as bloods and to act upon the results accordingly Cliicze condsfalate (by doctors and nurses) when signs of deterioration/change clinical condition become apparent in the patient's Doocs anarvaagingolrgentadditional tests and treatment (in this case radiological CT scanning; bloods and IV antibiotics) Split site commitmentireconfiguration and the impact this potentially has clinical care (please see above): upon patient safety and
Report sections
Investigation and inquest
On the 18th July 2016 commenced an investigation into the death of Mrs Kathleen Cooper:
Circumstances of the death
Mrs Cooper was 73 years of age at the time of her death. She admitted to the Royal Oldham Hospital on the 27lh June 2016 for elective surgery was necessary as she was suffering from severe diverticulitis sigmoid colectomy: The was carried out on the 28th June and was and bowel stricture. The operation relatively uneventful, However_ dheas technically coopetent The immediate post-operative period was Over Ine coueserof he Weekerd &Yt 8th July Cooper started to show subtle signs of deterioration, theatre on the the 11th her condition rapidly worsened. She was taken back to evening of the July but suffered an intra-operative cardiac arrest and advanced life support; she succumbed. Despite resuscitation ThsselospibarTrusts subsequent Root Cause Analysis (RCA') identified a number of errors, omissions missed opportunities to treat: and An inquest hearing was held on the 1St March 2017. Article 2 was (operational duty). engaged during the course of the inquest Following independent post mortem examination; the medical cause of death was established as: Ia) Acute intraoperative cardiac arrest due to myocardial ischaemia 1b) Sepsis due to faecal peritonitis Ic) Breakdown of colonic anastomosis following colectomy for diverticular stricture and diverticulitis
2) Coronary disease and hypertensive hear disease concluded narratively with a rider of medical and neglect: Trust and Mrs July, artery nursing admitted to the Roval Oldham Hospital on the 27th June 2016 for an elective The deceased was diverticular disease and bowel stricture: sigmoid colectomy, secondary to severe; long standing co-morbidities she was deemed medically fit for anaesthetic and Despite her pre-existing competent and the post ~operative period up until surgery: The operation itself was technically uneventful: However, by the 5th July the deceased started to show the 4th July 2016 relatively 8th marked deterioration set in: subtle signs of deterioration. By the weekend of the July very and nursing care afforded to the deceased during the course of the The standard of medical number of missed weekend of the 8th 11th July was significantly suboptimal: There were te treat a5 a result of the multiple errors and omissions that were made, Staff did opportunities rescue the deceased, in a timely manner, when she became perilously unwell not take steps to the deceased was in a critical condition:. Whilst a CT scan was By the morning of the 11 July, and/or in the eventually directed at 09:00 the same the request was completed medical staff until 12:00 13:00 hours and the scan was not performed until alternative sent by in extremis: When the scan was carried out, it 18.20 hours, by which time the deceased was that the bowel anastomosis had failed and there was evidence of a pelvic collection; showed to stabilize the deceased' $ condition, she underwent an emergency Following attempts deteriorated in theatre, culminating in cardio-respiratory arrest: laparotomy: Her condition and advanced life support, the deceased succumbed: She died at 23: 06 Despite resuscitation hours on the 11th July 2016,at the Royal Oldham Hospital Medical and nursing neglect more than minimally contributed to the deceaseds demise
2) Coronary disease and hypertensive hear disease concluded narratively with a rider of medical and neglect: Trust and Mrs July, artery nursing admitted to the Roval Oldham Hospital on the 27th June 2016 for an elective The deceased was diverticular disease and bowel stricture: sigmoid colectomy, secondary to severe; long standing co-morbidities she was deemed medically fit for anaesthetic and Despite her pre-existing competent and the post ~operative period up until surgery: The operation itself was technically uneventful: However, by the 5th July the deceased started to show the 4th July 2016 relatively 8th marked deterioration set in: subtle signs of deterioration. By the weekend of the July very and nursing care afforded to the deceased during the course of the The standard of medical number of missed weekend of the 8th 11th July was significantly suboptimal: There were te treat a5 a result of the multiple errors and omissions that were made, Staff did opportunities rescue the deceased, in a timely manner, when she became perilously unwell not take steps to the deceased was in a critical condition:. Whilst a CT scan was By the morning of the 11 July, and/or in the eventually directed at 09:00 the same the request was completed medical staff until 12:00 13:00 hours and the scan was not performed until alternative sent by in extremis: When the scan was carried out, it 18.20 hours, by which time the deceased was that the bowel anastomosis had failed and there was evidence of a pelvic collection; showed to stabilize the deceased' $ condition, she underwent an emergency Following attempts deteriorated in theatre, culminating in cardio-respiratory arrest: laparotomy: Her condition and advanced life support, the deceased succumbed: She died at 23: 06 Despite resuscitation hours on the 11th July 2016,at the Royal Oldham Hospital Medical and nursing neglect more than minimally contributed to the deceaseds demise
Action should be taken
In my opinion action should be taken to prevent future deaths and believe have the power to take such action; each of you respectively
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Report details
- Reference
- 2017-0063
- Date of report
- 8 March 2017
- Coroner
- Lisa Hashmi
- Coroner area
- Manchester City
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: 3 May 2017 (estimated).
Sent to
- Department of Health
- Pennine Acute Hospitals NHS Trust