Barbara White
13 Jan 2014 · Coroner Joanne Kearsley · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of clinical observations for 12 hours
“There was a lack of clinical observations for a period of 12 hours on the 9th December. In addition no nursing observations were carried out during this period of time.”
2. incorrect PARS score recorded
“At6 am Mrs [name redacted] PARS score was recorded as 2 when this should have been 5 which if correctly recorded would have led to medical intervention.”
3. staff shortage on Surgical Unit
“There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxillary nurse who was not familiar with the Surgical Unit. This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse [name redacted].”
4. lack of information in medical records after handover
“There was a lack of information in the patient's medical records following the handover from the day staff to the night staff. Following the review of Mrs [name redacted] on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant.”
5. lack of escalation to consultant after requested tests
“There was a lack of information in the patient's medical records following the handover from the day staff to the night staff. Following the review of Mrs [name redacted] on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest | heard evidence from Di who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was the she had no recollection of Mrs”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxillary nurse who was not familiar with the Surgical Unit.”
Later report
“The Ward Manager of Ward 31 confirmed in her evidence that, at the time of the care provided to Mr [name redacted], there was only one permanent substantive registered nurse working on the ward, with the vast majority of shifts being fulfilled by agency workers”
Responses
No published response was found on judiciary.uk.