Barry Thompson
11 Oct 2016 · Coroner Clare Doherty · Blackpool and Fylde
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of timely medical review and treatment
“Non-compliance with National and Local protocols: Mr [name redacted] was triaged as a high priority on admission to the Emergency department at 12.37 am on 26" February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital's) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care)”
2. inadequate monitoring of blood glucose and ketones
“Instructions were not given as to how frequently Mr [name redacted] blood sugar and ketones should be monitored. The evidence was that this should be every hour. After 16.15 hours there was one measurement of blood sugar and a later recording on the acute medical unit (untimed) and no measurement of ketones.”
3. incomplete fluid therapy and medication administration
“needs. There was difficulty encountered giving Mr [name redacted] saline by way of a drip. He was given an infusion of 1 litre over 4 hours at 17.30. At 23.00 it was found that the original cannula had become detached but the remaining fluid in the sac was 700mls. Mr [name redacted] bed was wet with saline fluid. He did not therefore receive the intended dose. He was not given a further injection of antibiotics 6 hours after the first nor was he written up for it. He was not given insulin. He does not appear to”
4. poor record keeping and information sharing
“Record keeping. /Information sharing. | found on hearing the evidence that records from both departments from 16.52 onwards are, inaccurate, infrequently made, disjointed and and incomplete causing them to be unreliable and affected continuity of care. Also this caused staff at the inquest not to be able to fully recall their actions”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“records from both departments from 16.52 onwards are, inaccurate, infrequently made, disjointed and and incomplete causing them to be unreliable and affected continuity of care”
Later report
“issues pertaining to the quality of record keeping.”
Closely relatedConfidence 0.82 · moderate
This report
“found on hearing the evidence that records from both departments from 16.52 onwards are, inaccurate, infrequently made, disjointed and and incomplete causing them to be unreliable and affected continuity of care.”
Later report
“There is a risk of future deaths because both patient care and the opportunity to learn valuable lessons following a death may be compromised by issues pertaining to the quality of record keeping and to the retention of records.”
Identical hazardConfidence 0.90 · high
This report
“He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital's) Sepsis Pathway.”
Later report
“there remains a risk that sepsis will go unrecognized, and urgent treatment will be delayed, putting patients attending Blackpool Victoria Hospital at risk”
Responses
No published response was found on judiciary.uk.