Source · Prevention of Future Deaths
Stanley Sampey
Ref: 2016-0191
Date: 18 May 2016
Coroner: S McGovern
Area: Warwickshire
Responses identified: 0 / 1
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The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.
Date
18 May 2016
56-day deadline
13 Jul 2016
Responses identified
0 of 1
Coroner's concerns
The ward lacked working suction equipment due to a flat battery and an incorrect, unstructured checking procedure, posing a risk to patient airway management.
View full coroner's concerns
_ _ There was no working available suction equipment on the Ward tO manage the patient's airway at the time of the cardiac arrest There was a lack of any structured checking procedure in place to ensure working suction equipment on wards The battery on the portable suction unit was found to be flat and the checking procedure was incorrect The
Report sections
Investigation and inquest
On 14 March 2016 commenced an investigation into the death of Stanley SAMPEY 92 years old. The investigation concluded at the end of the inquest on 13 May 2016. The conciusion of the inquest was accidental death_
Circumstances of the death
Mr Sampey was an in-patient at George Eliot Hospital While eating a meal in bed on 5 March 2018 he choked on a food bolus While medical staff were dealing with this incident they attempted to suction Mr Sampey's airway The wall mounted suction device was found not be working and when the crash trolley containing a portable suction unit arrived it was also not working;
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you as Chief Executive of the Trust have the power t0 take such action:
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Report details
- Reference
- 2016-0191
- Date of report
- 18 May 2016
- Coroner
- S McGovern
- Coroner area
- Warwickshire
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: 13 Jul 2016.
Sent to
- George Eliot Hospital