Source · Prevention of Future Deaths

Olive Darbyshire

Date: 22 May 2015 Coroner: Alan Wilson Area: Blackpool and The Fylde Responses identified: 1 / 1 View PDF

An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.

Date 22 May 2015

56-day deadline 17 Jul 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Although it is not possible to whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, am concerned that two senior Doctors gave evidence that they were expecting an urgent CTPA to have taken place that this had not happened some three days after the request was made am concerned that according to the Radiology department there is no record of the clinical team responsible for Mrs Darbyshire's care making efforts to "chase up" the missing CTPA procedure_ am concerned that the radiology department staff have incorrectly categorised Mrs Darbyshire in a way that meant that she spent a number of days in hospital awaiting an urgent CTPA procedure that in reality was not going to happen because once categorised as an outpatient she realistically would only expect to receive a CTPA in 2015 by way of a written notification_ am concerned that given this request was made on 23rd December 2014, subsequent events have been influenced by the fact that the request was made shortly before the Christmas period and that a lack of action taken by the clinical team to "chase up" the CTPA and the actions of the radiology department administration staff have been influenced by reduced staffing levels over the Christmas holiday period when the department would deal with inpatient requests only, and emergency requests pertaining to Accident & Emergency patients_

Responses

1 respondent

Olive Darbyshire

29 Jul 2015 PDF

Action Taken

Blackpool Teaching Hospitals NHS Foundation Trust has held meetings and created a Standard Operating Procedure (SOP) to improve the recording, tracing, and follow-up of diagnostic requests, ensuring all changes are complete and authorized. The SOP is awaiting ratification and submission to the Trust document library. (AI summary)

View full response

Dear Mr Wilson

Re: Response to Regulation 28 Report to Prevent Future Deaths Olive Darbyshire (deceased)

We thank you for your correspondence of the 22nd May 2015 in respect of Mrs Olive Darbyshire. The Trust takes seriously any concern raised by HM Coroner, and is committed to achieving improvements through lessons learnt, guidance, training and communication.

In response to your individual concerns we would advise the following:-

Concern 1

Although it is not possible to say whether a CTPA procedure would have had an impact upon when Mrs Darbyshire died, I am concerned that two senior doctors

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Blackpool Teaching Hospitals NHS NHS Foundation Trust

There have been several meetings of key team leaders and staff to look at how the Trust can put in place measures to reduce the weakness regarding the status of diagnostic requests, identification of the individual making the request, messaging and follow up.

This has led to the creation of a Standard Operating Procedure that defines situations leading to change and how messaging should be recorded and the requested action taken, step by step to ensure that all that is needed is recorded and can be traced back to the source of origin, ensuring that all changes are complete and authorised.

This covers several scenarios, where a patient or staff member may wish to change the status of the patient examination.

This will be ratified within the directorate and submitted to the Trust document library, where it can be accessed electronically by all staff, at any time.

Paper copies will also be available in key areas of the radiology department.

A copy of the procedure is attached for your convenience.

Thank you for bringing your concerns to the Trust's attention and if I can be of any further assistance please do not hesitate to contact me.

Report sections

Investigation and inquest

On April 2015 | opened an investigation into the death of Olive Darbyshire. inquest concluded on May 2015. The conclusion of the Coroner as to the death was a narrative conclusion as follows: Olive Darbyshire died of natural causes which were more than minimally, trivially or negligibly contributed to by a fall dated 22nd December 2014_ The medical cause of death was: la Multi Organ Failure Ib Acute intestinal haemorrhage Ic Ischaemic colitis fracture of left neck of femur following a fall [dated 22.12.14] and dalteparin therapy

Circumstances of the death

Olive Darbyshire suffered a fall on 22nd December 2014; She was trying to make her way from her bed to the toilet during the morning of 22nd December 2014 when she became tangled in her bedding and fell suffering a hip fracture. She was taken to hospital. She received dalteparin medication: Pulmonary embolism was suspected and an urgent CT Pulmonary Angiogram requested on 23 December to rule out a Pulmonary Embolism: The CTPA re quest was not acted upon. On 26th December 2014 a major intestinal bleed was detected. An endoscopy was carried out but there was no obvious source of the bleed found. Mrs Darbyshire passed away at 14.50 on 28th December 2014. The inquiry learnt that on 24th December the radiology department was provided with information which led to Mrs Darbyshire erroneously categorised as an outpatient: Despite an attempt later that to re-classify her as an inpatient; this was not acted upon she remained categorised as an outpatient the impact of which was that no CTPA was carried out prior to her death 2nd _ The 22nd being day and

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action:

Inquest conclusion

Olive Darbyshire died of natural causes which were more than minimally, trivially or negligibly contributed to by a fall dated 22nd December 2014_ The medical cause of death was: la Multi Organ Failure Ib Acute intestinal haemorrhage Ic Ischaemic colitis fracture of left neck of femur following a fall [dated 22.12.14] and dalteparin therapy

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Date of report: 22 May 2015
Coroner: Alan Wilson
Coroner area: Blackpool and The Fylde

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: 17 Jul 2015 (estimated).

Sent to

Blackpool Teaching Hospital NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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