Source · Prevention of Future Deaths

Marie Rollason

Ref: 2016-0100 Date: 24 Feb 2016 Coroner: Zafar Siddique Area: Black Country 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner raised concerns about a junior doctor's misinterpretation of an abnormal ECG trace and Mrs Rollason's subsequent discharge without further observation, identifying this as a missed opportunity for basic medical care and investigation.

Date 24 Feb 2016

56-day deadline 25 Apr 2016 stated in the report

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner raised concerns about a junior doctor's misinterpretation of an abnormal ECG trace and Mrs Rollason's subsequent discharge without further observation, identifying this as a missed opportunity for basic medical care and investigation.

View full coroner's concerns

Evidence emerged during the inquest that Mrs Rollason had at least five periods of loss of consciousness at home by the time she visited her GP's Practice on the 23 December 2015_ When she was admitted back to the Hospital on the 23 December 2015, an ECG trace revealed an abnormality in the trace which can be indicative of changes that occur during pulmonary embolism. However the Junior Doctor recorded the ECG trace 'was okay" She wasnt kept in for further observation but instead discharged and advised that if the dizzinesslfainting spells continue then she should be referred to a cardiologist via her GP_ This was effectively a missed opportunity to render basic medical care The Consultant who gave evidence suggested that the ECG trace was potential Red flag" and he would have admitted her for further observation given that she had no previous cardiac related complaints and to try and understand the basis for her loss of consciousness_ He went on to confirm in his opinion that on the balance of probability this was a failure in basic medical care Moreover, the inquest the Consultant gave evidence that in his opinion, had she been kept in Hospital and observed, then on the balance of probability it is more likely than not she may have survived. Further tests including the D Dimer test could have been done to confirm the diagnosis and appropriate treatment commenced

Responses

1 respondent

Royal Wolverhampton NHS Trust

NHS Trust

Indexed date: 22 Apr 2016 PDF

AI-classified response stance Action Taken

AI-generated response summary

• The Emergency Department provides regular training on the identification and treatment of pulmonary embolism. • A training session on venous thromboembolism was recently delivered within the Emergency Department. • Clinical staff directly involved in the management of Mrs Marie Rollason will receive individual training on interpreting ECG findings in patients with pulmonary embolism.

View full response

Dear Mr Siddique Re: Requlation 28: Report to Prevent Future_Deaths: Mrs Marie Rollason Inquest 19th February 2016 Thank you for your correspondence dated February 2016 regarding the outcome of the inquest into the death of Mrs Marie Rollason, concluding 19th February 2016. With respect to the action to be taken under regulation 28: report to prevent future deaths this was set out as follows: In my opinion action should be taken to prevent future deaths and believe you have the power to take such action"_ review should take place in the identification and treatment of pulmonary embolism and consideration of further training in the interpretation of ECG results for the staff involved _ can confirm that the clinical staff in the Emergency Department have regular training in the identification and treatment of pulmonary embolism and this subject is standard item on the teaching curriculum. A training session on venous thromboembolism has recently been delivered within the Emergency Department: The clinical staff directly involved in the management of Marie Rollason will have individual training in the interpretation of ECG findings in patients with pulmonary embolism specifically: Abnormalities in ECG tracings associated with pulmonary embolism are also included in the above noted training sessions_ If you do require further information please do not hesitate to contact me

Report sections

Investigation and inquest

On 30 December 2015, commenced an investigation into the death of Mrs Marie Rollason. The investigation concluded at the end of the inquest on 19 February 2016. The conclusion of the inquest was the deceased died by way ofnatural causes contributed to by neglect. The cause of death was: Ia. Pulmonary Embolism

Circumstances of the death

Mrs Rollason was a 43 year old woman who sustained a head injury during a fall in her bathroom at her home on the 19 December 2015. She was admitted to New Cross Hospital Emergency Department Wolverhampton at around 11.45pm. The laceration was sutured and computerised topography (CT) scan performed. The CT scan did not show any evidence of fractures or haemorrhages_ The injury was recorded as a laceration to the right side of forehead after a fall She was later discharged home the following morning on the 20 December shortly before 4am. She was provided with a leaflet advising that if she had any further loss of consciousness then she should seek medical attention. Over the course of the next several days she had & number of periods of loss of consciousness and was re-admitted back to the Accident and Emergency Department on the 23 December after she collapsedlfainted at her GP's surgery. She was examined at the same Hospital and her observations recorded An electrocardiogram (ECG) trace was also recorded. This revealed an abnormality in the trace which can be indicative of changes that occur during pulmonary embolism. However the Junior Doctor recorded the ECG trace 'was okay" and she wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP_ She continued to have fainting spells and loss of consciousness at home and then on_the_29_December_collapsed_again_ at_her_GP's_surgery_and_sadly: [ILI: PROTECT]

despite resuscitation attempts she died

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power t0 take such action. review should take place in the identification and treatment of Pulmonary Embolism and consideration of further training in the interpretation of ECG results for the staff involved.

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Shared signals

Report details

Reference: 2016-0100
Date of report: 24 February 2016
Coroner: Zafar Siddique
Coroner area: Black Country

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: 25 Apr 2016 (stated in the report).

Sent to

Royal Wolverhampton, New Cross Hospital

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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