Source · Prevention of Future Deaths

Olive Darbyshire

Date: 22 May 2015 Coroner: Alan Wilson Area: Blackpool and The Fylde Responses identified: 0 / 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 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
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.
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_

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

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Report details

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

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: 17 Jul 2015 (estimated).

Sent to

Blackpool Teaching Hospital NHS Foundation Trust

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