Source · Prevention of Future Deaths
Jessica Ashton-Pyatt
Ref: 2013-0200
Date: 30 Aug 2013
Coroner: ARW Forrest
Area: South Lincolnshire
Responses identified: 0 / 1
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The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Date
30 Aug 2013
56-day deadline
24 Oct 2013
Responses identified
0 of 1
Coroner's concerns
The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
View full coroner's concerns
_ The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation was not charged and no defibrillation pads were available.
Report sections
Investigation and inquest
On 2nd November 2012 ! commenced an investigation into the death of Jessica Florence Ashton-Pyatt, Age 14. The investigation concluded at the end of the inquest on 30"h August 2013 The conclusion of the inquest was spontaneous rupture of the stomach of uncertain cause; verdict was natural causes
Circumstances of the death
On 28th October 2012 Jessica became acutely unwell. On admission to the Accident and Emergency Unit at Pilgrim Hospital she was in extremis. Resuscitation attempts were unsuccessful. Post mortem showed her cause of death to be a ruptured stomach of uncertain, but natural cause
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire.gov.uk bay initially
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South_Lincolnshire
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Majesty's Senior Coroner for South_Lincolnshire
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Report details
- Reference
- 2013-0200
- Date of report
- 30 August 2013
- Coroner
- ARW Forrest
- Coroner area
- South Lincolnshire
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: 24 Oct 2013.
Sent to
- United Lincolnshire Hospitals NHS Trust