Source · Prevention of Future Deaths
Rosalind Adshead
Ref: 2014-0427
Date: 9 Sep 2014
Coroner: John Pollard
Area: Manchester (South
Responses identified: 0 / 2
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A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
Date
9 Sep 2014
56-day deadline
4 Nov 2014
Responses identified
0 of 2
Coroner's concerns
A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
View full coroner's concerns
During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak: She was a severely ill lady at this stage, the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that "it is not safe to transfer such a patient in the early hours of the morning" , that the transfer at this time "did add to the anxiety and distress in the middle of the night" and that "the shortage of ambulances in the normal working dayis not a valid excuse
Report sections
Investigation and inquest
On 30th April 2014 commenced an investigation into the death of ROSALIND ANN ADSHEAD born 22ND February 1945_ The investigation concluded on the 29"h August 2014 and the conclusion was one of MISADVENTURE The medical cause of death was Ia Pneumonia 1b Intra-abdominal adhesions and intestinal strictures (operated) Ic Previous gastric adenocarcinomas (operated) CIRCUMSTANCES OF THE DEATH: In 2007 Mrs_ Adshead underwent a total gastrectomy and then in 2014 she was found to have severe adhesions from that earlier surgery, which were causing strictures.
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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Report details
- Reference
- 2014-0427
- Date of report
- 9 September 2014
- Coroner
- John Pollard
- Coroner area
- Manchester (South
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Nov 2014.
Sent to
- N.W.A.S. NHS Trust
- Stockport NHS Foundation Trust