Source · Prevention of Future Deaths
Thomas Jordan
Date: 10 Aug 2016
Coroner: David Hinchliff
Area: West Yorkshire (East)
Responses identified: 0 / 2
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Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Date
10 Aug 2016
56-day deadline
5 Oct 2016 est.
Responses identified
0 of 2
Coroner's concerns
Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
View full coroner's concerns
_ (1) Healthcare staff at the Prison continued to administer the drug Digoxin for several days after the Clinicians at the Hospital had requested that it be discontinued: (2) There had been a breakdown in communication between the Hospital and the Prison when Mr Jordan was discharged.
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him; but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error; but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death (5) require that the Head of Healthcare at Her Majesty's Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison's Healthcare facility electronically to ensure that any directions advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose_
(3) The problem appears to be at the Prison as there was discharge correspondence sent back with him; but this was not immediately available to Healthcare staff and was not reviewed by them.
(4) This was an obvious drug error; but there is no evidence to conclude that this has materially caused or contributed to Mr Jordan's death (5) require that the Head of Healthcare at Her Majesty's Prison liaise with the Medical Director of the Leeds Teaching Hospitals NHS Trust to discuss the feasibility of discharge summaries in respect of Prisons being sent to the Prison's Healthcare facility electronically to ensure that any directions advice as to future care are received promptly and can take immediate effect.
(6) Should there be issues of patient confidentiality, this can be addressed by the Prison having a secure email facility dedicated for this purpose_
Report sections
Investigation and inquest
On 7th August 2015 commenced an Investigation into the death of Thomas George Jordan; aged 80 years. The Investigation concluded at the end of the Inquest on 28th June 2016. The Conclusion of the Inquest was: "Thomas George Jordan was a remand Prisoner at Her Majesty's Prison; Leeds who suffered with a number of chronic medical conditions as befits his age_ He became unwell and was admitted to St James's University Hospital, Leeds where his death was confirmed at 1955 hours on 6th August 2015" The cause of death being:- Ischaemic Heart Disease (b) Coronary Artery Atheroma Diabetes Mellitus_ Conclusion Natural Causes
Circumstances of the death
Thomas George Jordan was remanded in custody at Her Majesty's Prison, Leeds in April 2015 after breaching his bail conditions_ On the morning of 6th August 2015 his heart rate was fast and irregular. He was therefore admitted to Leeds General Infirmary with central chest pain; breathlessness, fast atrial fibrillation and low blood pressure_ He described having felt unwell for the previous three weeks: Clinically he was dehydrated and showed signs of kidney impairment and severe metabolic acidosis. He was reviewed by a Cardiologist and an ultrasound scan of his heart was performed. Later he was transferred to St James's University Hospital, Leeds, where his condition deteriorated . He went into cardiac arrest and despite cardiopulmonary resuscitation his death was confirmed at 1955 hours on 6" August 2015. 1(a)
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you ANDIOR your organisation have the power to take such action_
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Report details
- Date of report
- 10 August 2016
- Coroner
- David Hinchliff
- Coroner area
- West Yorkshire (East)
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: 5 Oct 2016 (estimated).
Sent to
- Her Majesty's Prison, Leeds
- The Leeds Teaching Hospitals NHS Trust
Part of a series
2016-0287
1/2