Source · Prevention of Future Deaths
Stephen Widman
Ref: 2014-0189
Date: 29 Apr 2014
Coroner: Ian Arrow
Area: Plymouth, Torbay & South Devon
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryThe coroner identified a need for an accelerated pathway for neutropenic sepsis patients to prevent prolonged A&E waits, and noted frequent catheterisation without urologist management. The report also suggested considering a vulnerable patient card to expedite emergency care.
Date
29 Apr 2014
56-day deadline
24 Jun 2014 est.
estimated from the report date
Responses identified
0 of 2
Coroner's concerns
The coroner identified a need for an accelerated pathway for neutropenic sepsis patients to prevent prolonged A&E waits, and noted frequent catheterisation without urologist management. The report also suggested considering a vulnerable patient card to expedite emergency care.
View full coroner's concerns
1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department.
2. The deceased was catheterised too frequently without the management of a urologist.
Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.
Action should be taken
Evidence was received that a Consultant could issue a vulnerable patient (particularly patients who are vulnerable because of cancer treatment) with a card to present at an Accident and Emergency Department which would read to the effect “I am vulnerable because .... please contact x on my behalf”. The evidence received was that this would be particularly helpful during weekends. The issue of such cards should be at the discretion of the Consultant having care of the patient.
I would ask Torbay Hospital and the Minister to consider the appropriateness of the issue of such cards.
Action should betaken
In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
Your response
You are under a duty to respond to this report within 56 days of the date of this report namely, 24th June 2014. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Copies and publication
I have sent a copy of my report to The Chief Coroner and to the following interested persons
Dittisham, South Devon
I am under a duty to send the Chief Coroners a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response to the Chief Coroner
I.M. ARROW
Dated 29th April, 2014 Senior Coroner – Plymouth, Torbay & South Devon
2. The deceased was catheterised too frequently without the management of a urologist.
Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number.
Action should be taken
Evidence was received that a Consultant could issue a vulnerable patient (particularly patients who are vulnerable because of cancer treatment) with a card to present at an Accident and Emergency Department which would read to the effect “I am vulnerable because .... please contact x on my behalf”. The evidence received was that this would be particularly helpful during weekends. The issue of such cards should be at the discretion of the Consultant having care of the patient.
I would ask Torbay Hospital and the Minister to consider the appropriateness of the issue of such cards.
Action should betaken
In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.
Your response
You are under a duty to respond to this report within 56 days of the date of this report namely, 24th June 2014. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
Copies and publication
I have sent a copy of my report to The Chief Coroner and to the following interested persons
Dittisham, South Devon
I am under a duty to send the Chief Coroners a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response to the Chief Coroner
I.M. ARROW
Dated 29th April, 2014 Senior Coroner – Plymouth, Torbay & South Devon
Similar PFD reports
Report details
- Reference
- 2014-0189
- Date of report
- 29 April 2014
- Coroner
- Ian Arrow
- Coroner area
- Plymouth, Torbay & South Devon
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: 24 Jun 2014 (estimated from the report date).
Sent to
- Department of Health and Social Care
- Torbay Hospital