Source · Prevention of Future Deaths

Stephen Mayoll

Ref: 2014-0515 Date: 25 Nov 2014 Coroner: David Horsley Area: Portsmouth & South East Hampshire Responses identified: 1 / 1 View PDF

The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.

Date 25 Nov 2014

56-day deadline 20 Jan 2015 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.

View full coroner's concerns

_ Qut-patients with similar injuries to Mr_Mayoll's returning_to the_fracture clinic at 28th 21s _

Queen Alexandra Hospital experiencing problems with their treatment or for periodic review are not subject to re-assessment under the hospital's DVT assessment policy: If they were, there would be less risk of their developing DVT's during the course of their treatment; 2-Evidence was given at the Inquest highlighting the delay in typing fracture clinic doctors' notes meaning that they would not always be available if an out-patient returned to the clinic and improved methods of making the notes available sooner to the clinic (e.g: by use of voice recognition IT) would obviate this problem.

Responses

1 respondent

Portsmouth Hospitals NHS Trust NHS / Health Body

25 Nov 2014 PDF

Action Planned

Patients returning to the fracture clinic with lower limb injuries will have a reassessment of their VTE risk factors. A scanner has been ordered to digitally save and record reviews by plaster technicians. (AI summary)

View full response

Dear Mr Horeley Requlation 28 Report regarding Mr_Stephen Mavoll deceased refer to your Regulatlon 28 Report of 25 November 2014 which the Truet has coneldered caretully. am pleaeed t be able to set out below the actions whlch we are Intending to tako t0 eneure ihat overythlng posolble Is done to prevent future caee8 euch &8 Mr Mayoll'e. Patlente wto retum to tha fracture cllnlc wlth lower limb Injurlos &8 "In trouble" or for routlne revlew, wll have a reassessment of thelr rlek factore for VTE oach tlmo attend, tho roeult of whlch will be considered by the doctor revlewlng them. Thle wlll be documented via the nomal route on & plaster room "In trouble" fomm Whlch Is cunontly belng updated and wlll Include tha recommendations which arose from the Inqueet rolatlng to VTE asses8ment, 2a. We wlll onsure that the review by the plaster techniclans will be recorded, signed and correctly dated and then scanned and saved by 'Windip" (an eleotronic storage system) s0 that If the palient returns again, the Informalion is avallable for the health care professional to view and follow the decision making and treatment plan from the previous vlsit, The scanner 'requlred for this to take place Is cunently on ordor: 2b. An "in trouble" patlent reviewed by the Consultant wll have the notos dictated that and then typed up by the Orthopaedic secretaries and the alm is for them t0 be typed within 24- hours, We are exploring IT solutions a8 well but thle Is Interim solutlon: The current EPRO system (a digital dictation system) Involves the notes typed up by egency staff and, possibly:in the future, outeide agencies and It Is anticipated that the nonal fypling turnaround will be at 48-hours by the end of March which Is still not qulck enough to ongure that information Is avallable for & Consultant revlewing & returlng patient; However, thore Ie the ablllty through EPRO to acces8 t0 the tapoe but the Consultante can Ileten to tho recordlng If the typed noteg are not avallable. Thle Ie belng fed back at the next consultants' meetlng; by way of reminder. thoy day the belng galn

hope that the above plan addreeees your concarns but of course please contact me again If you requlre any further clarificatlon or Informatlon. Youre gincerely Ursula Ward MSc MA Chlef Executlve

Report sections

Investigation and inquest

On June 2013 | commenced an investigation into the death of Stephen Anthony Mayoll, aged 44. The investigation concluded at the end of the inquest on 19th November 2014. The conclusion of the inquest was: Narrative Conclusion: On 10th June 2013 Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury for which he received treatment as an out-patient at Queen Alexandra Hospital, Portsmouth, between 11th and 20th June 2013_ 2-On June 2013 he became very unwell at home and was taken by ambulance to Queen Alexandra Hospital where he died at 03.20 hours on 22nd June 2013 He died as a result of complications of his injury and its treatment at the hospital between 11th and 20th June 2013,namely a pulmonary thromboembolism arising from a deep vein thrombosis in his right lower leg: Mr Mayoll did not fulfil the criteria then in force at the hospital for the use of anti-coagulation therapy in respect of Achilles tendon injury patients and in consequence did not receive such therapy which, on the balance of probabilities, would have reduced the risk of those complications arising:

Circumstances of the death

The circumstances of Mr Mayoll's death are set out in Paragraph 3 above_

Action should be taken

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

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Shared signals

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Report details

Reference: 2014-0515
Date of report: 25 November 2014
Coroner: David Horsley
Coroner area: Portsmouth & South East Hampshire

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: 20 Jan 2015 (estimated).

Sent to

Portsmouth Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.