Awa Jeng
20 Jan 2015 · Coroner Nadia Persaud · London (East)
The coroner's concerns
1. life threatening acute renal failure
“Mrs [name redacted] was at high risk of suffering life threatening acute renal failure. Her regular dialysis was due on the 19”
2. delayed blood gas testing
“The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19”
3. delayed blood gas testing
“The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level.”
4. communication failure
“It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her.”
5. insufficient nursing observations
“Mrs [name redacted] was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations.”
6. handover failure
“note that the Trust's internal investigation raised concerns in relation to the handover of responsibilities and tasks between day and night shifts.”
Responses
2015-0015-Response-by-Barts-Health-NHS-Trust.pdf ↗· Barts Health
Stated action · imminently
“the Trust is implementing a revised early warning score National Early Warning Score (NEWS) and Chronic Respiratory Early Warning Score (CREWS) which once implemented is expected to improve compliance with contacting and escalating assistance with deteriorating patients. This is being implemented at Newham University Hospital imminently, as well as across the Trust.”
Stated action · pilot approved
“Newham University Hospital has been awarded funding to implement a vital signs monitoring process known as Vitalslink which will transmit clinical observations to the Electronic Patient Record (EPR) by WI-FI and give real-time feedback to the clinician regarding at risk status and the appropriate action to take. This is currently being piloted at Newham University Hospital with wider roll-out planned once the pilot is approved.”
Stated action · under way
“the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift. This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved.”
Stated action · pilot approved
“The Vitalslink system will enable remote observation and alert for patients at risk - this can be used by the outreach team, ward managers and interested clinicians to rapidly detect patients even before the ward nurse has called in their concerns.”
Stated action · daily
“There is a daily consultant led trauma meeting in which all admissions, referrals, patients awaiting trauma surgery, post operative patients from the previous day and any sick patients under the care of the orthopaedic service are discussed”
Stated action · implemented
“Following your Report to Prevent Future Deaths, a section has been added for signing and dating the handover sheet between the member of the team involved and this sheet is retained in the orthopaedic department for audit and transparency purposes.”