Source · Prevention of Future Deaths

Denise Prior

Ref: 2014-0262 Date: 2 Jun 2014 Coroner: Michael Kendall Area: West Sussex Responses identified: 1 / 1 View PDF

Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.

Date 2 Jun 2014

56-day deadline 28 Jul 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.

View full coroner's concerns

In the circumstances it is my statutory duty to report to_YOU_ being again any yet

_ That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure the NEWS' system.

Responses

1 respondent

Western Sussex Hospitals NHS Trust NHS / Health Body

28 Jul 2014 PDF

Action Taken

Western Sussex Hospitals NHS Trust has undertaken a thorough investigation and review and enclosed an action log setting out the action taken. (AI summary)

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Dear Mr Kendall RE: Inquest into the death of Denise PRIOR ~ Regulation 28 response Thank you for your letter dated 3 June 2014, The Trust has undertaken a thorough investigation and review into the areas in which you raised concern and is pleased to enclose an action log setting out the action taken. hope that you will be reassured by the actions taken by the Trust and please do not hesitate to contact me should you require any further information or clarification.

Report sections

Investigation and inquest

On 20th May 2014 I concluded the inquest into the death of Denise PRIOR, born 18th February 1943 (aged 60 years) who died on 6th November 2013' Mrs Prior had died as a result of (1a) Global hypoxic ischaemic injury to the brain (1b) Hypoxia (1c) Facial injuries sustained in witnessed fall (29/10/13) (II) Debridement and closure of facial laceration, MUA plus oris of fractured nasal bones. Closure of intra oral laceration (successful 30/10/13). I determined that "The deceased died from a cardiac arrest following a fall caused by her underlying medical condition.

Circumstances of the death

Denise Prior died from the consequences of a cardiac arrest following fall, which in turn had been caused by her underlying medical condition. During inquest considerable attention was given to the concerns of Mrs Prior's family arising from the records of Mrs Prior's treatment at St Richards, which is part of the West Sussex Hospitals

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: 2014-0262
Date of report: 2 June 2014
Coroner: Michael Kendall
Coroner area: West Sussex

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: 28 Jul 2014 (estimated).

Sent to

Western Sussex Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.