Source · Prevention of Future Deaths

Paul Moroney

Ref: 2015-0043 Date: 4 Feb 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 1 / 1 View PDF

Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

Date 4 Feb 2015

56-day deadline 1 Apr 2015

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.

View full coroner's concerns

_ Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded Having been put on oxygen in the hospital, this was discontinued and he was sent home without his Oxygen saturations being monitored When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels and The day

Responses

1 respondent

Tameside Hospital NHS Trust NHS / Health Body

31 Mar 2015 PDF

Noted

The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the patient's notes as evidence. (AI summary)

View full response

Dear Mr Pollard Paul Moroney (Deceased) write further to your letter dated 4 February 2015 enclosing a Regulation 28 Report issued at the conclusion of the inquest into the death of Paul Moroney; which took place on 21 January 2015. am sorry that you found cause to issue this report and to address the concerns raised to your satisfaction in this letter. note that during the course of inquest you had three areas of concern: As the Trust were not legally represented at the inquest am we were not able to provide clarity at the have addressed the concerns as set out in Section 5 of your Regulation 28 Report as follows: Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded. On 27 August 2014, the patient was taken by ambulance to Tameside Hospital. patient's saturations were recorded as 70% on oxygen on 15LPM The nursing records then indicate the following: At 10.41 the patient's oxygen saturation levels were recorded as 98% on 15LPM of oxygen which is equal to a NEWS score of 0. At 11.30am, the patient's oxygen saturation levels were recorded as 100% on 15LPM of oxygen which is equal to a NEWS score of 0. At 12.22, the patient's oxygen saturation levels were recorded as 100% on 15LPM of oxygen which is equal to a NEWS score of 0. The patient was then discharged at 13.17pm by Dr Pattrick, Consultant in Acute Medical Unit with in-reach to Emergency Medicine hope that this reassures you that the oxygen saturations were monitored and recorded. can only apologise that the position in respect of the monitoring of the patients oxygen saturation levels was not fully communicated with the family, nor demonstrated to you at the inquest copy of the notes referred to are enclosed for your consideration. Everyone Mami very hope the sorry time The am,

Tameside Hospital NHS NHS Foundation Trust Should you have any further questions arising from the contents of this letter please do not hesitate to contact me_ am again that your investigation into this death caused you such significant concern to issue a Rule 28 letter but hope that you now suitably reassured Yours sincerel Director of Nursing On behalf of Karen James, Chief Executive Everyone Matrers sorry

Report sections

Investigation and inquest

On 3r September 2014 commenced an investigation into the death of Paul Moroney dob 7th November 1961 investigation concluded on the 21= January 2015 and the conclusion was one of "He died from the abuse of alcohol". The medical cause of death was 1a Dilated Cardiomyopathy 1b Chronic Alcoholism 11. Liver Cirrhosis and Steatosis

Circumstances of the death

On the 27th August 2014 he attended at Tameside Hospital by ambulance the ambulance proceeded to the hospital with full emergency equipment in operation, and the patient was given oxygen in the ambulance: Once at the hospital blood was taken and a bed-side X-ray was done: There was concern that he had had a blood clot; and it was arranged that he should return to the hospital the following for the administration of blood thinning agents: Shortly after returning home, his breathing got worse and a second emergency ambulance was called: The ambulance staff asked the patient why he had discharged himself from hospital and he told them that he had been discharged by the doctors_

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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Shared signals

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Report details

Reference: 2015-0043
Date of report: 4 February 2015
Coroner: John Pollard
Coroner area: Manchester (South)

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: 1 Apr 2015.

Sent to

Tameside Hospital Foundation NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.