Source · Prevention of Future Deaths

Peter Dorney

Ref: 2014-0504 Date: 17 Nov 2014 Coroner: Maria Voisin Area: Avon 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified that the Early Warning Score (EWS) protocol was not followed and EWS training for nurses is not mandatory, despite its importance for patient well-being.

Date 17 Nov 2014
56-day deadline 12 Jan 2015 est. estimated from the report date
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The coroner identified that the Early Warning Score (EWS) protocol was not followed and EWS training for nurses is not mandatory, despite its importance for patient well-being.
View full coroner's concerns
_ During the evidence the ward sister gave evidence and she was of the opinion that there should be mandatory training on EWS for nurses: It was clear in the evidence that the protocol in relation to the EWS score was not followed and was told that the EWS training_was not mandatory currently This case highlights why EWS scores are sO they 29th day important to the well-being of patients

Responses

1 respondent

North Bristol NHS Trust

NHS / Health Body
Letter dated 14 Jan 2015 PDF
AI-classified response stance Action Taken
AI-generated response summary

• The Trust stated that all new nurses receive mandatory Early Warning Score (EWS) training during induction. • Following the Regulation 28 report, the Trust reviewed staff training records and identified individuals who had not received EWS training. • The Trust indicated that the identified staff (7% of all nurses) would receive EWS training within the next three months.

View full response
Dear Ms Voisin, Re: Peter Dorney Inquest 14 November 2014, Regulation 28 Report Further to your narrative conclusion and concerns raised to North Bristol NHS Trust in the form of a Regulation 28 Report, am responding to confirm the Trust's actions: At the inquest, understand the Ward Sister gave evidence that Early Warning Score (EWS) training is not mandatory at the Trust for nurses and she was of the opinion that it should be This Is not completely accurate. All new nurses (both NBT Extra and NBT) receive mandatory EWS training on induction at the Trust; The clinical induction programme takes place over 3 days and includes 30 minute training session on EWSISBAR (Situation, Background, Assessment and Recommendation). This induction programme has been in place since 2011_ those nurses who been at the Trust to when this induction programme commenced, EWS training is not mandatory, but is carried out as appropriate. This training is included in nurse's Blue Passport (a training record used by every nurse) and carried out as appropriate i.e. when member of staff is deemed to require it: Training requirements are discussed at an individuals annual appraisal and during the course of the year; if necessary; have set out below the system at the Trust In relation to EWS training: North Bristol Trust implemented the Bristol Observation Chart in 2007 a8 part of joint safety prior have For

collaborative work with University Hospitals Bristol: The Bristol chart makes it very clear when patient triggers an EWS, and our policy covers the process of escalation to medical staff that must be responded to within timed period depending on the severity of the score As mentioned above; all new nurses are trained on induction in the EWS score; and the vast majority of nurses have had this training: Since receiving the Regulation 28 directorate has reviewed which individuals have not received the Report; each for those individuals to receive this training and measures are being in place This has been limited to a few staff that have been employed at North Bristol NHS Trust for more than a few years. As of 13 January 2015,our records show that 93% of all nurses (both NBT extra and NBT) have received EWS training: This is well abave ur target range for compliancy within any given subject; which is assessed at 85%. confident that we have the right EWS training in place for all nurses, and that am few individual nurses (7% as of 13 January 2015) that have been Identified as those the training following a review by each directorate, will have received not receiving the training within the next 3 months.

Report sections

Circumstances of the death
Peter Dorney was admitted into Frenchay Hospital on March, during his admission it was clear that he was not a well man: During the ward round on 3rd April there was no evidence at that time of a chest infection: Overnight on 3*/4" April the nurse caring for Peter Dorney said that at 22.00 hours his EWS score was 2 due to his low oxygen saturations_ This score of 2 should have resulted in her informing the nurse in charge and increasing his observations to hourly. In evidence she said that it was her intention to do both of these things and that she should have but she didn't When Peter Dorney's observations were carried out at 07.40 hours on 4"h April he was now very unwell and his EWS was 5. Appropriate action was then taken however later that he suffered a cardiac arrest and died:
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:

Similar PFD reports

Shared signals

Report details

Reference
2014-0504
Date of report
17 November 2014
Coroner
Maria Voisin
Coroner area
Avon

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: 12 Jan 2015 (estimated from the report date).

Sent to

Southmead Hospital

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