Source · Prevention of Future Deaths

Rose Jean Coles

Ref: 2013-0246 Date: 27 Sep 2013 Coroner: Maria Voisin Area: Avon Responses identified: 1 / 1 View PDF

Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.

Date 27 Sep 2013

56-day deadline 22 Nov 2013 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.

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 Education

25 Oct 2013 PDF

Action Planned

University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures. (AI summary)

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

Related inquiry recommendations

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).

Sent to

University Hospitals Bristol NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.