Source · Prevention of Future Deaths

George Marks

Ref: 2015-0057 Date: 17 Feb 2015 Coroner: Kate Thomas Area: Mid Kent & Medway Responses identified: 1 / 1 View PDF

Agency staff demonstrated a fundamental lack of understanding regarding medication administration policies, prescription chart recording, patient nursing notes documentation, and correct handover procedures.

Date 17 Feb 2015

56-day deadline 14 Apr 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

_
1) Agency staff failed to have an understanding of the basic policies and procedures in place when administering medication and / or where a patient refused to take such medication_
2) Agency Staff failed to have an understanding of the Prescription Chart and / or failed to make any record_ or any adequate record in the said chart
3) Agency Staff failed to have an understanding of the need to make a record and or any adequate record in the patients nursing notes,
4) Agency Staff failed to adopt the correct "Hand Over' procedure_

Responses

1 respondent

Mayday Healthcare NHS Trust

17 Feb 2015 PDF

Action Taken

Mayday Healthcare has implemented measures including monthly SMS reminders to staff, consultant training, client feedback forms, quarterly letters to staff, and updated yearly training program in regards to documentation, escalation, administration of medication and compassion. (AI summary)

View full response

Dear Madam, Re: Response to the inquest touching on the death of George Marks: We are in response to your letter dated 17 February 2015, we initially responded to you detailing the measurements that would be implemented in order to prevent a case such as this ever arising again. We have included a copy of the original letter that had been sent detailing those measurements, due to the initial timeframe in which we had to adopt these new processes were initially designed. However, am pleased to say that after three months these measures has been implemented and nurses are now reminded of their basic duties outlined by the NMC guidelines: Please see below a brief outline of the measurements that have now been implemented since the initial letter dated 24 November 2014, which detailed our proposal for change: generic SMS has been sent to all staff detailing the importance of documentation, escalation, administration of medication and compassion. This is done once a month to remind all staff of their basic duties All consultants that liaise with staff are now trained to remind the nurses of their basic duties before undertaking a shift and this has now been enforced amongst existing consultants as well as incorporated in to the training of new recruits_ Feedback forms have been created and are distributed to clients on a regular basis, requesting for clinical work to be monitored and checked in accordance with the NMC guidelines. Formal letters sent to all staff, detailing the importance of documentation, escalation, administration of medication and compassion. This is currently done every quarter. RS( Recruitment & Employment Confederation Registered office: Hygeia 66-68 College Road, Harrow; Middx HAT 1BE. Tel: 020 8861 3000. Registered in England and Wales No: 04983787. 3 Yealthca? Jay writing they being being

Updated our yearly training program in regards to documentation, escalation, administration of medication and compassion, which is outside of the framework requirements for the Mandatory Training subjects We must state that our proposed changes and have been running for past three months and they now feature permanently in Mayday Healthcare PLCs working practises If you have any further questions or concerns please do not hesitate to contact me_

Report sections

Investigation and inquest

On the 20th of March 2014 | commenced an investigation into the death of George Marks, Aged 93. The investigation concluded at the end of the inquest on the 5th of November 2014. The conclusion of the inquest was natural causes contributed to by neglect:

Circumstances of the death

Mr Marks was admitted in to A&E Dept on the 14th of February 2014 with confusion, immobility and chest infection_ He was prescribed anticoagulant medication as a precaution given his age and immobility _ The diagnosis of DVT was confirmed on the 24th of February when scans showed he had DVT in the leg and right sided thrombus in the pulmonary artery On the 27th of February a decision was made to change anticoagulant medication to Rivoroxaban administered orally . On the 27th of February Mr Marks was cared for by the first of succession of agency nurses from the Mayday Healthcare PLC. From the evening of the 28th' of February until the 4th of March, when Doctor finally noticed, Mr Marks had failed to be given his medication and in particular the Rivoroxaban which was located in a 'pod' beside his bed. the

Mr Marks declined and died on the 8"h of March 2014, A Consultant Haematologist at the Inquest said that it was unlikely that new embolism would have formed had Mr Marks been administered Rivoroxaban and further, that there was a very high probability that the new embolism caused or contributed to his death

Action should be taken

In my opinion action should be taken to prevent future deaths and | believe organisation have the power to take such action:

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2015-0057
Date of report: 17 February 2015
Coroner: Kate Thomas
Coroner area: Mid Kent & Medway

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: 14 Apr 2015 (estimated).

Sent to

Mayday Health Care Plc

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.