Phillip Pratt

During the course of the inquest, , Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. gave

[Page 3] evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which I understand action has not yet been taken. The matters of concern I raise are as follows: (1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication; (2) As it was not expected the patient would remain at hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed; (3) The onset of agitation and confusion had been recognized, with a (4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication; (5) There was a delay in x-raying the shoulder. The report comments (6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available. In my opinion action should be taken in order to prevent the risk of future deaths and I believe your organisation has the power to take such action. You are required to respond to this letter within 56 days of the date of this report, namely by the 1st October 2013. If you are unable to reply within this time, you may apply for an extension. The response must contain details of action taken or proposed to be taken, setting out the timetable for such action. If no action is to be taken, you must explain why no action is proposed. A copy of this report is being sent to the Chief Coroner and to who was identified as an interested person at the inquest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner. Yours sincerely, Elisabeth Bussey-Jones

[Page 4] Assistant Coroner for West Sussex