Source · Prevention of Future Deaths

Hayley Clark

Ref: 2016-0143 Date: 12 Apr 2016 Coroner: Mark Beresford Area: Yorkshire South (East District) Responses identified: 1 / 1 View PDF

Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

Date 12 Apr 2016

56-day deadline 7 Jun 2016 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Staff failed to adjust the paracetamol dosage to reflect the patient's extremely low body weight, indicating a lack of appropriate medication management.

View full coroner's concerns

In the circumstances it is my statutory to report to you: Coroner'$ Court and Office, Doncaster Crown Court; Road, Doncaster, DNI 3HS Tel 01302 737135 Fax 01302 736365 The May long May duty College.

(1) There was a failure on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark's extremely low body weight.

Responses

1 respondent

The Rotherham NHS Trust NHS / Health Body

PDF

Action Planned

An action plan is in place to ensure correct management of oral paracetamol for adult patients of extremely low body weight, including updating the drug chart, developing information for staff, and providing additional training. An audit of documentation of weights recorded in relevant nursing records and charts and on prescription charts will be undertaken. (AI summary)

View full response

Dear Mr Beresford

RE: Ms Hayley Clark – Regulation 28

Firstly, I wish to state on behalf of The Rotherham NHS Foundation Trust, how sorry we are for the shortcomings in practice relating to Ms Clark’s care. We have taken the learning from our investigation and your concerns seriously in order to improve practice and take action to ensure that other patients do not have the same experience in future.

Turning to the specific issues that you identified in your conclusion at the inquest on the 12th of April 2016:

“There was a failure, on the part of the staff who prescribed and administered the paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight”

I attach a copy of our additional action plan and can confirm that I am assured that the Patient Safety Group will oversee completion of the action plan. In the meantime please do not hesitate to contact me if you require any further information

Report sections

Investigation and inquest

On 27/05/2015 commenced an investigation into the death of Hayley Christine Clark, 36. The investigation concluded at the end of the inquest on 12 April 2016 conclusion of the inquest was a Narrative conclusion as follows: Hayley Christine Clark died, at Rotherham Hospital, on 24th 2015,from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort_ The cause of death was 1a. Respiratory failure; 1b Pulmonary oedema, Ic Severe multi-iactorial malnutrition; Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency

Circumstances of the death

Hayley Christine Clark was a 36 years old female with a medical background which included term malnutrition , hypogammaglobulinemia, irritable bowel syndrome_ anaemia and depression She was admitted to Rotherham General Hospital on 12"h May 2015 with electrolyte imbalance. As part of a standard package of pain management; Ms Clark received Paracetamol, However the dose administered was the standard adult one and had not been adjusted to reflect Ms Clark's extremely low (less than 50kg) body weight. This overdose of Paracetamol caused derangement of Ms Clark's liver function. The problem was identified, the Paracetamol was withdrawn and Parvolex was administered. Ms Clark's condition deteriorated. She was transferred to the High Dependency Unit on 22nd 2015 and she died on 24th May 2015. The cause of her death was as set out above_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you Ms Louise Barnett; Chief Executive, have the power to take such action.

Inquest conclusion

Hayley Christine Clark died, at Rotherham Hospital, on 24th 2015,from the effects of severe malnutrition. Her malnutrition arose from a combination of factors, which did not include anorexia, but which did include poor eating discipline due, in part, to longstanding abdominal discomfort_ The cause of death was 1a. Respiratory failure; 1b Pulmonary oedema, Ic Severe multi-iactorial malnutrition; Acute pyelonephritis, electrolyte imbalance, anaemia and immune deficiency

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Report details

Reference: 2016-0143
Date of report: 12 April 2016
Coroner: Mark Beresford
Coroner area: Yorkshire South (East District)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 7 Jun 2016 (estimated).

Sent to

Rotherham Hospital NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.