Burton Hospitals NHS
NHS / Health Body
Action Taken
AI-generated response summary
• The Trust stated that staff receive training on incident reporting, including procedures for using paper-based forms during system downtime. • The Trust confirmed that additional training and support for Ward 6 had been arranged. • The Trust provided an explanation that a CT scan was not indicated for the patient, citing adherence to NICE head injury guidance.
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Dear Mr Haigh Re: Elsie TREECE (Deceased) In response to the HM Coroner's Prevention of Future Death Report received by the Trust following the inquest of Elsie Treece [B332952]. In relation to incident reporting, can confirm that training has always been provided for staff in relation to the reporting of incidents. This training has been delivered by the Clinical Risk Team in collaboration with the Learning and Development Team: Registers of attendance are collated by the Learning and Development Team and entered against the annual training requirements for each staff member and uploaded onto the ESR system: Currently training is provided at Trust induction days, mandatory update training days, online training and ad hoc sessions in ward and department areas and provided for medical staff in different forum_ Ad hoc training is provided as requested, and in light of this request for information from HM Coroner; we have arranged to provide additional training and support for Ward 6. More recently, we have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting and the feedback mechanisms Which occur Whilst it has been acknowledged that there was period of downtime for the HISS computer system which occurred the time of Mrs Treece's admission, contingency plans were in place which instigated the use of paper based documentation, and including paper based incident forms_ Those paper incident forms received during and following the downtime were manually entered into the electronic system. With regard to point 2 of concern as to the reasons why Mrs Treece did not have a CT scan. Please find attached letter from Joutlining the reasons why a CT scan was not appropriate_ Yours sincerely 793 LY Helen Ashley Chief Executive: Att_ WKZO2SA May May during put
Burton Hospitals [NH NHS Foundation Trust Queen's Hospital Belvedere Road Burton upon Trent Staffordshire DE13 ORB ref JACIEG Telephone 23 January 2014 BURTOWh eriAL3NHS JAUST T2 ?leCAL SeAvICES ' Legal Services Manager T Queen's Hospital Jam Bridget Re: Elsie Treece DoB: 2/6/1918 Mr Haigh has asked Trust to look at the case of Mrs Elsie Treece who the Emergency Department on 18 2013 at 0317hrs specific attended to find out why Mrs Treece did not have CT scan on that question was She was seen by Foundation Year 2 Doctor at 04OOhrs , after triage which showed that she was alert with normal observationste routine assessed her noted that she was suffering from The Doctor who her bed, where she landed a head injury, following a fall on the She sustained a laceration to the right forehead, without any evidence of loss of consciousnees, her normal conscious level. He also noted vomiting or reduction in alert and that she was not on Warfarin and was comfortable on examination. have also looked at the West Midlands Ambulance Service regarding her transfer t0 the EmergencyaDepartmenlaand agairicehidocorroeoraiog thee Doctors notes where there was no evidence of loss of consciousnessr she was alert with a normal conscious level. and also Her symptoms and signs were not consistent with significant head injury and therefore Wehwould not have proceeded to do a CT scan as per NICE head guidance. There was no indication to out a CT scan at the time: thanks
Burton Hospitals [NH NHS Foundation Trust Queen's Hospital Belvedere Road Burton upon Trent Staffordshire DE13 ORB ref JACIEG Telephone 23 January 2014 BURTOWh eriAL3NHS JAUST T2 ?leCAL SeAvICES ' Legal Services Manager T Queen's Hospital Jam Bridget Re: Elsie Treece DoB: 2/6/1918 Mr Haigh has asked Trust to look at the case of Mrs Elsie Treece who the Emergency Department on 18 2013 at 0317hrs specific attended to find out why Mrs Treece did not have CT scan on that question was She was seen by Foundation Year 2 Doctor at 04OOhrs , after triage which showed that she was alert with normal observationste routine assessed her noted that she was suffering from The Doctor who her bed, where she landed a head injury, following a fall on the She sustained a laceration to the right forehead, without any evidence of loss of consciousnees, her normal conscious level. He also noted vomiting or reduction in alert and that she was not on Warfarin and was comfortable on examination. have also looked at the West Midlands Ambulance Service regarding her transfer t0 the EmergencyaDepartmenlaand agairicehidocorroeoraiog thee Doctors notes where there was no evidence of loss of consciousnessr she was alert with a normal conscious level. and also Her symptoms and signs were not consistent with significant head injury and therefore Wehwould not have proceeded to do a CT scan as per NICE head guidance. There was no indication to out a CT scan at the time: thanks