Source · Prevention of Future Deaths
Christopher Williams
Ref: 2014-0131
Date: 19 Mar 2014
Coroner: Alan Moore
Area: Cheshire
Responses identified: 0 / 1
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A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Date
19 Mar 2014
56-day deadline
14 May 2014
Responses identified
0 of 1
Coroner's concerns
A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
View full coroner's concerns
(1) The defibrillator machine did not work, even when the battery pack was changed.
(2) The defibrillator had not been checked on 5 November, although there was a requirement for the equipment to be checked daily for serviceability by the nursing staff.
(3) There was no ‘cross-check’ or ‘double check’ system in place.
(4) There was no policy or protocol in place at the hospital for the management of sudden / unexpected deaths.
(2) The defibrillator had not been checked on 5 November, although there was a requirement for the equipment to be checked daily for serviceability by the nursing staff.
(3) There was no ‘cross-check’ or ‘double check’ system in place.
(4) There was no policy or protocol in place at the hospital for the management of sudden / unexpected deaths.
Report sections
Investigation and inquest
On 11 November 2013 I commenced an investigation into the death of Christopher Ricardo WILLIAMS, then aged 50. The investigation concluded at the end of the inquest on 7 March 2014. The conclusion of the inquest was Natural Causes and the medical cause of death was Massive Pulmonary Embolism.
Circumstances of the death
(1) At the time of his death Christopher was detained under Section 37 of the Mental Health Act 1983. He was resident at Adams Ward, St Mary’s Hospital, Warrington, Cheshire. Adams Ward is a medium secure unit.
(2) On 5 November 2013 Christopher complained of shortness of breath during the previous few days. He had a past medical history of pulmonary tuberculosis. He was seen by the GP the same day. The GP diagnosed a chest infection and prescribed antibiotics.
(3) Christopher was subject to Level 1 observations (every 30 minutes). Throughout the night, up to and including the check at 5.30 am on 6 November 2013, Christopher appeared to be sleeping in his bed, giving no cause for concern. At 6 am he was found to be out of bed, kneeling on the floor against the bed. He appeared to be ‘snoring’ but was unresponsive. An ambulance was called.
(4) A defibrillator machine was brought from an adjacent ward. The defibrillator did not work. Staff changed the battery pack but the defibrillator still did not work.
(5) A second defibrillator machine was sent for but by the time it had arrived the ambulance paramedics were already at the scene.
(6) Christopher was pronounced dead at the scene at approximately 6.30 am. 2
(2) On 5 November 2013 Christopher complained of shortness of breath during the previous few days. He had a past medical history of pulmonary tuberculosis. He was seen by the GP the same day. The GP diagnosed a chest infection and prescribed antibiotics.
(3) Christopher was subject to Level 1 observations (every 30 minutes). Throughout the night, up to and including the check at 5.30 am on 6 November 2013, Christopher appeared to be sleeping in his bed, giving no cause for concern. At 6 am he was found to be out of bed, kneeling on the floor against the bed. He appeared to be ‘snoring’ but was unresponsive. An ambulance was called.
(4) A defibrillator machine was brought from an adjacent ward. The defibrillator did not work. Staff changed the battery pack but the defibrillator still did not work.
(5) A second defibrillator machine was sent for but by the time it had arrived the ambulance paramedics were already at the scene.
(6) Christopher was pronounced dead at the scene at approximately 6.30 am. 2
Copies sent to
National Offender Management ServiceIndependent Advisory Panel on Deaths in custody
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Report details
- Reference
- 2014-0131
- Date of report
- 19 March 2014
- Coroner
- Alan Moore
- Coroner area
- Cheshire
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 14 May 2014.
Sent to
- St Mary’s Hospital Warrington
Part of a series
2019-0183
All responses identified