Source · Prevention of Future Deaths
Alan Walker
Date: 14 Dec 2015
Coroner: John Gittins
Area: North Wales (East and Central)
Responses identified: 0 / 1
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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
0 of 1
Coroner's concerns
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
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;
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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
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Feb 2016.
Sent to
- BCUHB, Ysbyty Gwynedd