Source · Prevention of Future Deaths
Sally Froggatt
Ref: 2016-0481
Date: 11 May 2016
Coroner: James Adeley
Area: Preston and West Lancashire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner raised concerns regarding inadequate staff training and a failure to comply with the duty of Candour. It was also noted that corporate pharmacy guidelines contradicted NICE guidance and nursing staff did not alert consultants to known risk factors.
Date
11 May 2016
56-day deadline
5 Jul 2016
stated in the report
Responses identified
0 of 1
Coroner's concerns
The coroner raised concerns regarding inadequate staff training and a failure to comply with the duty of Candour. It was also noted that corporate pharmacy guidelines contradicted NICE guidance and nursing staff did not alert consultants to known risk factors.
View full coroner's concerns
a failure to comply with the of Candour inadequate training of staff corporate pharmacy guideline documentation that appears to contradict the NICE guidance referred to in other corporate literature failure of BMI nursing staff to raise known risk factors with consultants
Report sections
Investigation and inquest
On 07/04/2015 commenced an investigation into the death of Sally Ann Tooze Froggatt, aged 52 The investigation concluded at the end of the inquest on 03/05/2016. The conclusion of the inquest was: Sally Ann Tooze Froggatt died on 6 April 2015 at Royal Lancaster infirmary following multiple missed opportunities by clinicians to treat her high risk of venous thromboembolism that would have saved her life. Further opportunities for live saving measures were lost both at discharge and during a cancelled follow up telephone call from a clinician:
Circumstances of the death
The circumstances of the death are fully set out in the attached Summing Up and Expressions of Concern:
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
Report details
- Reference
- 2016-0481
- Date of report
- 11 May 2016
- Coroner
- James Adeley
- Coroner area
- Preston and West Lancashire
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: 5 Jul 2016 (stated in the report).
Sent to
- BMI Health Care