Recurance · prevention of future deaths reports
Pre-inquest brief
Inaccurate early warning score calculation by clinical staff
The earlier warning
Jude Augustus Gordon · 24 Sept 2013 · Donald Coutts-Wood, South Yorkshire (West)
“It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual.”
judiciary.uk/prevention-of-future-death-reports/gordon-2013-0237
What was promised
Stated action 1 · response to Jude Augustus Gordon (24 Sept 2013) · stated timescale: July 2012
“work is already being taken forward. In July 2012 a report entitled National early warning score (NEWS); standardising the assessment of acute-illness severity in the NHS, was published by the Royal College of Physicians.”
judiciary.uk/…/2013-0237-Response-by-Department-of-Health.pdf
Stated action 2 · response to Jude Augustus Gordon (24 Sept 2013) · stated timescale: none stated
“The system operational in a Birmingham Trust depends on patient observations being recorded in the Patient Information Communication System (PICS), the Trust's rules-based clinical information, drug prescribing and administration system. As observations are entered an early warning score is generated. Depending on the score generated and the settings programmed, an automatic message can be sent to designated nursing and medical staff.”
judiciary.uk/…/2013-0237-Response-by-Department-of-Health.pdf
What recurred
- 19 Jul 2017 · Edith Robinson · Lisa Hashmi · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Jude Augustus Gordon · 24 Sept 2013
“It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual.”
Later · Edith Robinson · 19 Jul 2017
“there - were problems with the Registered Nurses' ability to calculate early warning scores accurately”
What happened next
No web check of the stated actions has been published for this chain.