Source · Prevention of Future Deaths

Rose Jean Coles

Ref: 2013-0246 Date: 27 Sep 2013 Coroner: Maria Voisin Area: Avon 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified insufficient communication between the neonatal intensive care unit and the cardiac unit, which was considered unsuited for premature babies, indicating a need for improved protocols or checklists.

Date 27 Sep 2013

56-day deadline 22 Nov 2013 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified insufficient communication between the neonatal intensive care unit and the cardiac unit, which was considered unsuited for premature babies, indicating a need for improved protocols or checklists.

View full coroner's concerns

Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward

Responses

1 respondent

University Hospital Bristol

NHS Trust

Indexed date: 25 Oct 2013 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Trust provided a composite action plan addressing the matters of concern. • The Trust stated many actions described within the plan were already in hand. • The Trust confirmed the action plan would be monitored through its governance procedures to ensure full implementation.

View full response

Dear Mrs Voisin Regulation 28 Report Ref 00231/20012 and Ref 03754/2012 Further to the recent inquests, into the deaths of Jared McDowall and Rose Coles, please find attached a composite action plan addressing the matters of concern addressed within the two Regulation 28 Reports issued to the Trust on the Ist October 2013. The Trust is confident that the actions described, many of which are already in hand, will address the concerns expressed and mitigate the risk identified of future deaths attributable to these factors_ The action plan will be monitored through the Trust's governance procedures to ensure its full implementation. Please do not hesitate to contact me if you require any further information_

Report sections

Investigation and inquest

On 23rd November 2012 commenced an investigation into the death of Rose Jean COLES, Aged month The investigation concluded at the end of the inquest on 12"h September 2013. The conclusion of the inquest was Ia Congenital heart disease (operated)

Circumstances of the death

Rose Coles was born prematurely at 34 weeks gestation on 4ih October 2012, she had congenital heart disease and received treatment for this She died at 09.50 hours on 13"h November 2012 at the Bristol Royal Hospital for Children;

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action.

Similar PFD reports

Shared signals

Report details

Reference: 2013-0246
Date of report: 27 September 2013
Coroner: Maria Voisin
Coroner area: Avon

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Nov 2013 (estimated from the report date).

Sent to

University Hospitals Bristol NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.