The Dudley Group NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review, and the electronic clinical information system will be reconfigured to create a visible alert to the consultant in charge when a patient's vital signs fall outside normal parameters. (AI summary)
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The Dudley Group NHS] NHS Foundation Trust Ref:RJB Black Country Coroner's District_ In the matter of MrJohn Dodd Response to Requlation 28 Report to Prevent Future_Deaths make this submission in my capacity as Medical Director at The Dudley Group NHS Foundation Trust 2 Facts The facts are out in the enclosed chronology_
3. The_following issues_have_been raised bYHM Coroner The deceased, (Mr John Dodd) was on warfarin but the INR was not checked on 16th April 2013 despite the degree of pain and history of fall. There was a rise in temperature of nearly degree on the afternoon of 16th April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a back ground of paracetamol being administered. I_ It was the evidence ofl that he would have wanted to know about this above) and would have wanted the patient assessed medically to the actual discharge from the department: This did not happen: IV There was considerable on the night of the 20th April between the arrival of Mr Dodd in A&E V_ And his first assessment by a medically qualified member of staff vis: 20.44-00.23 Current_practice at _The_Dudley Group_NHS Foundation Trust International normalised ratio (INR) is not routinely checked in all patients with the clinical presentation of the patient on 16/04/13,
i.e. with non-truncal injury or head, lacking visible swelling or bruising and having vital signs within normal limits_ A rise in temperature between 36.6 (at 1007) and
37.5 at (1434) would not always require referral to medical staff by the nurse if the patients vital signs fall within acceptable parameters based on the National Early Warning System (NEWS) as set prior delay
The Dudley Group NHS] NHS Foundation Trust recommended by the Royal College of Nursing, Royal College of Physicians and the College of Emergency Medicine M The consultant responsible is made aware of any patient whose vital signs are outside of acceptable parameters, based on NEWS: IV All staff are trained to recognise abnormal vital signs the NEWS The current clinical electronic information system indicates to the doctor any patient whose vital signs fall outside normal parameters_ However, the consultant must access the individual patient record in order to see the alert. 5_ Actions to Prevent Future_Deaths The following actions together address H.M Coroner's concerns |-V above: written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants_ such as warfarin. The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review when presenting to the Emergency Department. Additionally; The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patients vital signs fall outside normal parameters: All of the above actions will facilitate a reduction in the delay highlighted in points |-IV above 6_ Review of Actions The lead nurse and consultant in the Emergency Department will be responsible for ensuring actions changes are implemented. The first three actions will be carried out within two months and the fourth within four months_ using
The Dudley Group [HS] NHS Foundation Trust A report will be presented by the Medical Director & Director of Nursing to the Clinical Quality, Safety & Patient Experience Board Sub-Committee, which will be responsible for ensuring that actions are implemented_ DRAF
3. The_following issues_have_been raised bYHM Coroner The deceased, (Mr John Dodd) was on warfarin but the INR was not checked on 16th April 2013 despite the degree of pain and history of fall. There was a rise in temperature of nearly degree on the afternoon of 16th April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a back ground of paracetamol being administered. I_ It was the evidence ofl that he would have wanted to know about this above) and would have wanted the patient assessed medically to the actual discharge from the department: This did not happen: IV There was considerable on the night of the 20th April between the arrival of Mr Dodd in A&E V_ And his first assessment by a medically qualified member of staff vis: 20.44-00.23 Current_practice at _The_Dudley Group_NHS Foundation Trust International normalised ratio (INR) is not routinely checked in all patients with the clinical presentation of the patient on 16/04/13,
i.e. with non-truncal injury or head, lacking visible swelling or bruising and having vital signs within normal limits_ A rise in temperature between 36.6 (at 1007) and
37.5 at (1434) would not always require referral to medical staff by the nurse if the patients vital signs fall within acceptable parameters based on the National Early Warning System (NEWS) as set prior delay
The Dudley Group NHS] NHS Foundation Trust recommended by the Royal College of Nursing, Royal College of Physicians and the College of Emergency Medicine M The consultant responsible is made aware of any patient whose vital signs are outside of acceptable parameters, based on NEWS: IV All staff are trained to recognise abnormal vital signs the NEWS The current clinical electronic information system indicates to the doctor any patient whose vital signs fall outside normal parameters_ However, the consultant must access the individual patient record in order to see the alert. 5_ Actions to Prevent Future_Deaths The following actions together address H.M Coroner's concerns |-V above: written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants_ such as warfarin. The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff. The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review when presenting to the Emergency Department. Additionally; The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patients vital signs fall outside normal parameters: All of the above actions will facilitate a reduction in the delay highlighted in points |-IV above 6_ Review of Actions The lead nurse and consultant in the Emergency Department will be responsible for ensuring actions changes are implemented. The first three actions will be carried out within two months and the fourth within four months_ using
The Dudley Group [HS] NHS Foundation Trust A report will be presented by the Medical Director & Director of Nursing to the Clinical Quality, Safety & Patient Experience Board Sub-Committee, which will be responsible for ensuring that actions are implemented_ DRAF