Darren Goddard
9 Mar 2020 · Coroner Sarah-Jane Richards · South Wales Central
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. misleading emphasis on flu-like symptoms as adverse effects
“TRUS elective surgery 'consenting' and information provision (oral and in written format) places a misleading emphasis on flu-like symptoms as adverse effects”
2. inaccuracy of sepsis risk incidence
“The accuracy of the 1% risk of sepsis incidence provided”
3. premature discharge missed sepsis recognition
“Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred”
4. failure to escalate referral within 10 minutes
“The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission”
5. failure to provide timely fluids and antibiotics
“Subsequent failure to provide timely and appropriate fluids and antibiotics”
6. delay in critical care admission
“Delay in admission to Critical Care”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“(4) The failure at triage to escalate this referral to seeing a doctor within 10 mins of admission.”
Later report
“The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts”
Closely relatedConfidence 0.80 · moderate
This report
“(3) Premature discharge post-operatively from the recovery unit with the missed opportunity to recognise the adverse effect of sepsis when they occurred.”
Later report
“[the deceased] should have been referred for surgical review rather than being discharged.”
Responses
2020-0060-Response-from-Dr-Hopkins-Redacted.pdf ↗· Cwm Taf Morgannwg University Health Board
Stated action · 11 March 2020
“Review and provide definite warnings (oral and written) of sepsis when consenting patients to TRUS, and upon their discharge.”
Stated action
“We can confirm that a single leaflet, which is produced by the British Association of Urological Surgeons (BAUS), is now used, which states that patients should expect to go home on the same day, with no specific time scales given.”
Stated action · ongoing (held on hold due to COVID-19)
“Further training of Triage nursing staff and doctors of the sepsis 6 bundle and =e} Score (NEWS) documentation, escalation and the implementation of the Sepsis 6 bundle.”
Stated action
“will also ensure that point of care testing for venous blood gases is introduced in order to identify abnormal lactate results, which are key to the early identification of sepsis.”
Stated action
“The learning from your report and the University Health Board's own investigations has been shared with individual staff, and also across the organisation via the Health Board's Listening & Learning Feedback Newsletter.”