Source · Prevention of Future Deaths

David Price

Ref: 2015-0210 Date: 1 Jun 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 0 / 2 View PDF

Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.

Date 1 Jun 2015
56-day deadline 27 Jul 2015 est.
Responses identified 0 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Problems included uncontrolled warfarin prescriptions without clinic attendance, very poor quality handwritten medical notes, failure to act on a radiologist's finding of a foreign body, and an unsatisfactory swab count policy during surgery.
View full coroner's concerns
In the circumstances it is my statutory to report to you: The__ Glyn graft duty

1.Before he was admitted to hospital his G.P. was prescribing warfarin and this continued over many months despite the fact that he failed on three occasions to attend the anti-coagulation clinic. There is apparently no system to prevent this happening: have noted in many inquests that people who have "repeat prescriptions" continue to all the drugs prescribed even if are no longer needed or wanted, thus potentially placing the patient at considerable health risk but also costing the NHS a vast amount of money for unwanted and unused drugs (For the Secretary of State)
2. The quality of the handwritten notes (both medical and nursing) was nothing short of very poor: were frequently undated, unsigned and there was no indication in block letters as to who was completing the notes, hislher professional status etc (For UHSM) Even though a "specialist radiologist" looked at the X-Rays, and noted that appeared to show a foreign body within the thorax of the patient; this was not read or seen by any of the treating doctors, or if it was seen it was not in any way acted upon: (This was of course an image of the rogue swab which was left in the body:) (UHSM)
4. There did not seem to be in place any, or any satisfactory, swab count policy, such that none of the nurses during any of the three heart procedures, noticed that there was a discrepancy (UHSM)

Report sections

Investigation and inquest
On 8TH January 2015 commenced an investigation into the death of David Price dob 2nd October 1959. The investigation concluded on the 1st June 2015 and the conclusion was one of Accidental Death. The medical cause of death was 1a Previous myocardial infarction; treated by coronary artery bypass and mitral valve disease treated by valve replacement 11. Steato-hepatitis: peri-cardial abscess
Circumstances of the death
In early June 2011 he suffered a heart attack and was operated on at Wythenshawe Hospital. In the course of the operative procedures, swab was inadvertently left inside his body attached to his heart: This gradually formed an abscess.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Report details

Reference
2015-0210
Date of report
1 June 2015
Coroner
John Pollard
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Jul 2015 (estimated).

Sent to

Department of Health and Social Care
Manchester University NHS Foundation Trust

Part of a series

2 reports
2019-0145 All responses identified

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