Source · Prevention of Future Deaths

Keith Thomas Graham

Ref: 2013-0327 Date: 4 Dec 2013 Coroner: D.Ll. Roberts Area: North and West Cumbria Responses identified: 0 / 1 View PDF

The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and minimising time to surgery when indicated.

Date 4 Dec 2013
56-day deadline 20 Apr 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and minimising time to surgery when indicated.
View full coroner's concerns
In the circumstances it is my statutory duty t0 report to you. as set out in 4 above To review the procedures to deal with seriously injured_trauma patients on arrival at A & cycle He May:

Eto include the of the summons to the on call Clinicians, the contra for the use of CT Scanning, and where surgery is indicated, minimising
-indications presentation and theatre. the time between

Report sections

Investigation and inquest
On the 30"h May 2012 commenced an investigation into the death of Keith Thomas Graham aged 45 years_ The investigation concluded at the end of the inquest on the 29"h November 2013. Cause of death Multiple Injuries_ On the 22nd' May 2012 the deceased Ieft a public house in Burgh by Sands on his motor having consumed three pints of beer. He travelled along the c.2042 road at high speed when he was in collision with a bullock was transported to the Cumberland Infirmary, Carlisle where he underwent surgery, dying from his injuries on the 28lh The conclusion of the inquest was Road Traffic Collision.
Circumstances of the death
The deceased was involved in a Road Traffic Collision He reached the Cumberland Infirmary, Carlisle at 20.08 hours He was in a poor condition. It was planned that he be taken to a CT Scanner which occurred at 21.20 hours_ He was suffering from Hypotension and was taken to Theatre at 21.30 hours. The on call Consultant was not contacted until 21.15 hours_ A chest drain was misplaced and caused damage to the liver . He underwent a Throacotomy and three Laparotomies in the space of some 5 Vz hours. The consensus of medical evidence was that on the balance of probabilities he would have died of his injuries in any event,
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action. you ANDIOR

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Report details

Reference
2013-0327
Date of report
4 December 2013
Coroner
D.Ll. Roberts
Coroner area
North and West Cumbria

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: 20 Apr 2014 (estimated).

Sent to

North Cumbria University Hospitals NHS Trust, The Cumberland Infirmary

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