Denise Prior

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.

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 NHS Foundation Trust: In particular the records of her oxygen levels on 30th and 31st October 2013 were examined at length heard evidence from several witnesses employed by the Trust, and concluded that there was conflicting evidence as to the precise reason for her cardiac arrest but no evidence to support finding that on balance of probabilities her cardiac arrest had been Caused by any failure by the Trust or its employees to administer oxygen or any other treatment required by her condition_ the the

Nevertheless I expressed serious concerns about the standard of record-keeping on the Middleton Ward of St Richard's hospital: I found that the evidence showed particularly in respect of the Patient Observation Charts and the application of the National Early Warning Score ('NEWS') system (i) that the '02 SATS entries had been completed in the wrong line on four occasions on 30th October; (ii) that the total score of Mrs Prior's readings had been incorrectly calculated on five occasions on 3Oth October; (iii) that on three occasions on 30th October the patient's total 'NEWS' score amounted to 5, while individual scores of her oxygen levels were at '3' on one occasion on 30th October, and that according to the notes about the 'NEWS' system any total of or individual score of 3 required monitoring to be increased in frequency "to minimum of hourly" and for "trained nurse to urgently inform the medical team caring for the patient" and for an "urgent assessment within hour by a clinician with core competencies to assess acutely ill patients_ There was no record that these steps were taken nor of the outcome, nor alternatively that any reasons existed why they should not be taken, nor that any assessment had been made that Mrs Prior's "normal parameters" would have allowed more relaxed monitoring regime or application of the 'NEWS' system; (iv) that while nurses were expected to use their experience in assessing the condition of patients and the course of action required, including any departure from the 'NEWS' system, the observation charts did not include any written record of such an assessment having been made, nor any croSs-reference to any other records that might suggest that alternative courses of action were justified; (v) that the Prescription and Administration charts contained no record of oxygen prescribed nor of the level of such prescription; (vi) that while supplementary evidence was given that steps had already been taken to introduce a computerised Patient Track' record system in the previous 2 years, and that such a system would ensure that observations were recorded correctly and that 'NEWS' score totals and alerts would be correctly indicated, that system had not been working on 30th and 31st October and on other occasions, during which the paper records already referred to were used instead , and would be used in the future during breakdown; moreover the computerised system did not in any event record the prescription of oxygen levels, and an oxygen administration audit had not been commissioned_

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