Source · Prevention of Future Deaths

Michael Richardson

Ref: 2015-0114 Date: 24 Mar 2015 Coroner: David Osborne Area: Norfolk Responses identified: 1 / 1 View PDF

Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

Date 24 Mar 2015

56-day deadline 19 May 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Critical information from ambulance reports, such as a patient's nutritional status, was not adequately reviewed during hospital admission, risking adverse outcomes if not addressed.

View full coroner's concerns

In the circumstances it is my statutory to report to you _ There was within Mr Richardson's records an ambulance crew report which recorded that Mr Richardson was said to have not eaten for 5 days. In evidence before me it was confirmed that the ambulance report would have been available to the person who undertook the MUST screen. It also appeared that this may not have been reviewed at the time. If it had been reviewed the evidence given before me was to the effect that the information might have led to a MUST score of 2 which in turn have led to a referral to dietician services Although the expert evidence was that Mr Richardson's nutrition did not play a material part in his death, am nevertheless concerned that in' different circumstances a failure to follow up information or review the ambulance record andlor any other records with which a patient is admitted and aged duty would so miss the information could affect the outcome for the palient and that there is therefore a risk of future deaths.

Responses

1 respondent

James Paget University Hospitals NHS Trust NHS / Health Body

PDF

Noted

Response is unintelligible due to formatting issues. (AI summary)

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Report sections

Investigation and inquest

On 18 March 2014 | commenced an investigation into the death of Michael Barry Richardson 66 years The investigation concluded at the end of the inquest on 18 March 2015 The conclusion of the inquest was that the medical cause of dealh was Ia Bronchopneumonia, 1b Pulmonary Fibrosis, 2 Pulmonary hypertension and Ischaemic Heart Disease and that Mr Richardson died from natural causes_

Circumstances of the death

Mr Richardson was admitted to the James Paget University Hospital on 24 October 2013 following a deterioration in his lung disease He was diagnosed as suffering from an infective exacerbation of his pulmonary fibrosis and a community acquired pneumonia Despite treatment he arrested and died on 27 October 2013. On admission a MUST screen was carried out by a student nurse with a score of 0.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have Ihe power to take such action

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Shared signals

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Report details

Reference: 2015-0114
Date of report: 24 March 2015
Coroner: David Osborne
Coroner area: Norfolk

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: 19 May 2015 (estimated).

Sent to

James Paget University Hospital NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.