Source · Prevention of Future Deaths

Douglas Kay

Ref: 2016-0033 Date: 5 Feb 2016 Coroner: Elizabeth Didcock Area: Nottinghamshire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified significant confusion and uncertainty regarding policies for transferring patients with gastrointestinal bleeding within the Trust. Senior staff at Bassetlaw Hospital were also unaware of the new Doncaster Hospital service's operational details, particularly out of hours.

Date 5 Feb 2016

56-day deadline 1 Apr 2016 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified significant confusion and uncertainty regarding policies for transferring patients with gastrointestinal bleeding within the Trust. Senior staff at Bassetlaw Hospital were also unaware of the new Doncaster Hospital service's operational details, particularly out of hours.

View full coroner's concerns

_ There remain significant confusion, and uncertainty about how, when, to transfer a patient with gastrointestinal bleeding, with no clear agreed policy or procedure available within the Trust There are new arrangements for the provision of a gastrointestinal bleeding service at Doncaster Hospital, but Senior staff at Bassetlaw Hospital are not aware of how it operates, particularly out of hours_

Responses

1 respondent

DBH Trust

NHS Trust

Indexed date: 1 Apr 2016 PDF

AI-classified response stance Action Planned

AI-generated response summary

• A new Upper GI Bleed Transfer Policy for Bassetlaw Hospital has been developed. • All staff will be made aware of the transfer policy through the Clinical Site Manager and Matron. • The policy will be ratified at the next Patient Safety Review Group meeting and its implementation will be monitored.

View full response

Dear Dr Didcock write with respect to the concluded inquest on Douglas and the Regulation 28 report dated 5 February 2016 where concerns been highlighted with respect to arrangements for the management and transfer of patients with gastrointestinal bleeding (GI Bleed) at Bassetlaw Hospital The report was addressed to the Chief Executive of the Doncaster & Bassetlaw Hospitals NHS Foundation Trust and have been tasked with addressing the issues identified in your report: have been assisted in the course of this by Consultant Gastroenterologist and clinical lead for GI bleeding with contributions from Dr Gurgit Singh, Consultant Gastroenterologist, Bassetlaw Hospital and Dr Vinesh Vincent, Consultant Anaesthetist/Intensivist at the same hospital: attach two documents with respect to the concerns highlighted. Document 1 is the standard GI bleed pathway for any patient presenting with a gastro-intestinal bleed to the Doncaster & Bassetlaw Hospitals NHS Foundation Trust: The 2nd document and the one Kay have

which is particularly relevant in this case is the Upper GI Bleed Transfer Policy at Bassetlaw Hospital for those patients who require to be referred to Doncaster for further management of their upper GI bleeding: This policy has been developed after consultation between the anaesthetic and the medical teams All staff will be made aware of this specific transfer policy at Bassetlaw through the Clinical Site Manager and Matron at Bassetlaw: The policy will also be ratified at the next meeting of the Patient Safety Review Group and this will ensure wider dissemination throughout the Trust_ trust that this will provide the assurance you require that appropriate action has been taken following the death of Douglas Kay: The implementation will continue to be monitored by the Emergency Care Group Clinical Governance Team through the Datix incident system: May take this opportunity to invite vou to revert back to me should you feel it necessary to do so.

Report sections

Investigation and inquest

On the 1st December 2014, commenced an investigation into the death of aged 90 years. The investigation concluded at the end of the inquest on Douglas August 2015. The conclusion of the inquest was one of Natural Causes

Circumstances of the death

Mr was an elderly man, but was reasonably fit for his age; He presented to Bassetlaw Hospital with bleeding from a duodenal ulcer on 16'h November 2014. He was admitted, monitored and given medication to try and heal the ulcer. On the evening of the 22nd November; Mr became suddenly unwell with clear evidence of active bleeding from the ulcer, with a blood stained vomit and black stools. This was a catastrophic bleed and despite attempts to resuscitate he died approximately 7 hours later. Throughout the period of his deterioration there was significant confusion about the arrangements for a possible transfer to Doncaster Hospital for further treatment. The Trust completed an Investigation report;, produced an action plan, and submitted further reports during the Inquest: All these documents went some way to addressing concerns raised in evidence, however, in my view there remain outstanding concerns that allow for the continuation of circumstances creating a risk that other deaths will occur if such matters are not addressed_

Action should be taken

In my opinion_action should be_taken to prevent future deaths and believe you have Kay, Kay Kay him, and key the power to take such action_

Similar PFD reports

Shared signals

Report details

Reference: 2016-0033
Date of report: 5 February 2016
Coroner: Elizabeth Didcock
Coroner area: Nottinghamshire

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: 1 Apr 2016 (estimated from the report date).

Sent to

Doncaster and Bassetlaw Hospital NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.