Source · Prevention of Future Deaths
Linda Rignall
Ref: 2014-0414
Date: 19 Sep 2014
Coroner: Veronica Hamilton-Deeley
Area: Brighton & Hove
Responses identified: 0 / 1
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A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Date
19 Sep 2014
56-day deadline
14 Nov 2014 est.
Responses identified
0 of 1
Coroner's concerns
A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
View full coroner's concerns
At 17.33 on the 5"h May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart:
Report sections
Investigation and inquest
On 7th 2014 commenced an investigation into the death of LINDA ANNE RIGNALL.The investigation concluded at the end of the inquest on 4th September 2014.The conclusion of the inquest was a Narrative Conclusion
Circumstances of the death
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths occur unless action is taken: In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows: At 17.33 on the 5"h May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart: This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have_been assessed. The_position worsened some 4 City and May will
VERONICA HAMILTON-DEELEY, LLB.
VERONICA HAMILTON-DEELEY, LLB.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action.
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Report details
- Reference
- 2014-0414
- Date of report
- 19 September 2014
- Coroner
- Veronica Hamilton-Deeley
- Coroner area
- Brighton & Hove
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 Nov 2014 (estimated).
Sent to
- Royal Sussex County Hospital