Source · Prevention of Future Deaths

William Joseph Wilkinson

Ref: 2013-0294 Date: 11 Nov 2013 Coroner: John Pollard Area: Manchester South Responses identified: 0 / 1 View PDF

Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.

Date 11 Nov 2013
56-day deadline 21 Feb 2014 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Deficient one-to-one nursing, computer system failures, incomplete medical records, and absence of direct orthopaedic input in A&E contributed to an unnecessary admission and subsequent death.
View full coroner's concerns
A number of issues were raised by members of staff and others about the care at the Royal Bolton Hospital as foilows was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available. There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his death (2) Members of staff reported that they sometimes find it difficult if not impossible to log onto the computer system in the hospital and theretore cannot record matters as they should be recorded. This is apparently due to the inadequacies of the system rather than the inabilities of the individuals.

(3) A Fluid Balance Chart was ordered to be kept and it was accepted that this was not done and an incomplete Fluid Balance Chart resulted.

(4) It was agreed that there was no direct orthopaedic input available at the Emergency Department at the hospital and that it would be sensible for this to have been available_ Had this been available Mr Wilkinson would probably not have been admitted to the hospital in the first place with a fractured ankle and therefore would not_presumably_have developed clostridium difficile leading_to his death He was described as an unnecessary in-patient

Report sections

Investigation and inquest
On the 19"h of December 2012 an investigation was commenced into the death of William Joseph Wilkinson. The investigation concluded at the end of the Inquest on 9 September 2013. The conclusion of the Inquest was that the deceased died an accidental death_
Circumstances of the death
Mr Wilkinson slipped on the pavement whilst he was out shopping on or about the 9th of December 2012 and he fractured his ankle. He was admitted to the hospital and thereafter complications occurred leading to his death:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:

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Report details

Reference
2013-0294
Date of report
11 November 2013
Coroner
John Pollard
Coroner area
Manchester South

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: 21 Feb 2014 (estimated).

Sent to

Royal Bolton Hospital

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