Source · Prevention of Future Deaths

Alan Walker

Date: 14 Dec 2015 Coroner: John Gittins Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.

Date 14 Dec 2015

56-day deadline 8 Feb 2016

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Critical information was not consistently recorded in nursing notes, and handovers did not reference these records, risking significant patient details being missed by incoming staff.

View full coroner's concerns

That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time day from feeding any

Responses

1 respondent

Alan Walker

10 Feb 2016 PDF

Action Planned

The Health Board has considered the concerns regarding poor record keeping and incomplete handover arrangements and has enclosed a working action plan that will be monitored for timely progress. (AI summary)

View full response

Dear Mr Gittins

Re: Regulation 28 letter in respect of Alan Walker

Further to your Regulation 28 notification to the Health Board following the inquest of Alan Walker.

The Health Board has considered your concerns in relation to poor record keeping and incomplete handover arrangements.

Therefore please find enclosed a working action plan relating to this case. The action plan will be monitored to ensure timely progress.

Report sections

Investigation and inquest

On the 24th of January 2014 commenced an investigation into the death of Alan Walker (DOB 11.08.32, DOD 23.01.14). The investigation concluded at the end of the inquest on the 11th of December 2015 and recorded a conclusion of Accidental Death

Circumstances of the death

(a) The Circumstances of the death are that on the 22nd of January 2014 a nasogastric feeding set was connected to the IV Iine of the deceased, which resulted in the intravenous infusion of liquid feed as a consequence of which he died the following due to 1(a) Toxic Shock (b) During the afternoon of the 22n the NG tube had become detached the set on two occasions in quick succession and had thereafter been taped together, however these events were not recorded in the nursing notes and therefore other staff were not made aware that there may be a connectivity issue with this equipment during handover. Furthermore, staff handovers may not in event be conducted by way of reference to the nursing notes

Action should be taken

In my opinion action should be taken t prevent future deaths and believe your organisations have the power to take such action;

Similar PFD reports

Shared signals

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Report details

Date of report: 14 December 2015
Coroner: John Gittins
Coroner area: North Wales (East and Central)

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: 8 Feb 2016.

Sent to

BCUHB, Ysbyty Gwynedd

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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