Source · Prevention of Future Deaths
Martha Davies
Ref: 2016-0331
Date: 16 Sep 2016
Coroner: Caroline Beasley-Murray
Area: Essex
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified serious communication failings and an over-reliance on agency and junior staff to make decisions. Concerns were also raised about the lack of a prompt response to the patient's deteriorating state and documentation issues.
Date
16 Sep 2016
56-day deadline
11 Nov 2016
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner identified serious communication failings and an over-reliance on agency and junior staff to make decisions. Concerns were also raised about the lack of a prompt response to the patient's deteriorating state and documentation issues.
View full coroner's concerns
Cont…… (1) Serious failings in communication between shifts, with senior staff, and at multi-disciplinary meetings (2) Over reliance upon agency staff and on junior staff to make decisions (3) Lack of prompt response to the patient’s deteriorating state.
(4) Lack of engagement of ward staff and ward manager (5) Failings in the documentation
(4) Lack of engagement of ward staff and ward manager (5) Failings in the documentation
Report sections
Investigation and inquest
On 16 May 2016 I reopened the inquest touching upon the death of Martha Ann Davies. The cause of death was 1a) subdural haematoma 1b) multifactorial fall 11)fracture neck of femur (treated)
The jury’s conclusion at the end of the inquest was a narrative conclusion:- Martha Ann Davies died as a result of an accident. We agree that Mrs Martha Ann Davies was given adequate and appropriate care at Colchester Hospital University Foundation Trust, that Mrs Martha Ann Davies did not receive adequate care and appropriate treatment at Clacton District Hospital and that this may have contributed to her death
The jury’s conclusion at the end of the inquest was a narrative conclusion:- Martha Ann Davies died as a result of an accident. We agree that Mrs Martha Ann Davies was given adequate and appropriate care at Colchester Hospital University Foundation Trust, that Mrs Martha Ann Davies did not receive adequate care and appropriate treatment at Clacton District Hospital and that this may have contributed to her death
Circumstances of the death
The deceased, a very fit 98 year old lady, fell at home and was admitted to Colchester Hospital on 11 October 2015 where she received surgery for a fractured hip. On 7 November she was then transferred to Clacton Hospital for rehabilitation. On 17 November she suffered a fall and she was transferred to Colchester Hospital on 19 November. She died there on 29 November.
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Report details
- Reference
- 2016-0331
- Date of report
- 16 September 2016
- Coroner
- Caroline Beasley-Murray
- Coroner area
- Essex
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 Nov 2016 (stated in the report).
Sent to
- Anglian Community Enterprise